Health Funding
	 — 
	Question

Baroness Walmsley: To ask Her Majesty’s Government whether they carried out an equality impact assessment before deciding on the recent in-year budget cut to public health funding.

Lord Prior of Brampton: My Lords, we pay close attention to equalities considerations when deciding how to distribute the public health grant between local authorities. The Department of Health is about to consult on how to implement the savings and we will address our equalities duties in full when announcing our final decisions.

Baroness Walmsley: My Lords, I thank the Minister for his reply, but given that these cuts will impact on teenage pregnancy programmes for the young, domestic violence programmes for women, HIV prevention programmes for gay men and some members of the BME community and TB prevention programmes for the poor and homeless, will he say where the equality is in that?

Lord Prior of Brampton: The noble Baroness will know that decisions on these matters are left to local authorities, and we wish to give them as much discretion as we can.

Lord Hunt of Kings Heath: My Lords, there is not much discretion if the Treasury decides to take away £200 million in-year on public health programmes from local authorities. If the intention is to squeeze the public health budget, will the Government therefore take action at national level to compensate for this by legislating to reduce the amount of fat, salt and sugar in food and drinks that are aimed mainly at children and young people?

Lord Prior of Brampton: My Lords, prevention is very important to the Government and a very important part of the NHSFive Year Forward View. The reduction of £200 million in the grant to local authorities should be seen in the context of a total grant of £3.2 billion; it is a 6% reduction. Public Health England has a campaign to raise awareness of the damage that sugar and salt, as well as smoking and alcohol, can do to people’s lives.

Baroness Howarth of Breckland: My Lords, if the noble Lord takes into consideration not only the cuts to this budget but those to other local authority budgets, he will see that this will mean a reduction in
	youth services, the closure of young people’s centres and a range of preventive services for children being reduced. Will that not have a cumulative effect on the general health of the nation, and certainly on the protection of children?

Lord Prior of Brampton: My Lords, the NHS is facing a challenge over the next five years to achieve productivity savings of some £22 billion. If we wish to have a sustainable, tax-funded health service in the long term, we have to make these savings. I have no doubt that over this time this will cause difficulties, but, again, it has to be seen in the context that we have a national debt of more than £1 trillion and a public sector borrowing requirement that must come down.

Baroness McIntosh of Hudnall: My Lords, does the Minister not agree that, of all the places to cut the National Health Service budget, it is incredibly short-sighted to do so in areas to do with prevention because, although there may be short-term savings to be made there, in the long term it will build up problems which will cost a great deal more in the future?

Lord Prior of Brampton: I repeat my earlier response that prevention is extremely important. We are looking at a relatively small reduction of £200 million out of a total public health budget of more than £5 billion.

Baroness Masham of Ilton: My Lords, does this mean that campaigns on alcohol and drug abuse will be cut? Is the Minister aware that there is a great increase in liver disease and hepatitis C?

Lord Prior of Brampton: The decisions about which services to reduce must lie with local authorities.

Baroness Janke: My Lords, does the Minister realise that many of the contracts for public health are already let in the medium term? Is the proposed cut on uncommitted funding, or are the Government proposing to give some help to local authorities who have no way of ending those contracts?

Lord Prior of Brampton: The noble Baroness raises a good question. This will be a crucial part of our consultation, which will take place very soon.

Lord Harrison: Does the Minister not recognise that, as was the case in our recent debate on diabetes, wise investment in public spending on health can save billions later, not only in terms of the tragedies in the lives of people who experience suffering from something such as diabetes but also in the weight placed on the public purse to fund the health service?

Lord Prior of Brampton: I agree fully with the noble Lord. Early prevention is crucial, not just for diabetes but for a whole range of mental health issues as well, and prevention will remain a critical part of the five-year forward view.

Lord Mawhinney: My Lords, will my noble friend make arrangements for someone to survey local supermarket shelves and record the number of items for sale that have either no added sugar or are sugar free? Will he then arrange for a similar survey to be conducted among the major supermarkets in the United
	States? After which, will he explain to us what government policy will be applied to try to get us even in the same vicinity as the sugar reductions that are available to American purchasers?

Lord Prior of Brampton: My noble friend raises a very interesting point. I will certainly bring it to the attention of Public Health England and, depending on their reaction, I will be happy to come back to the House and give the noble Lord the answer to his question.

Lord Howarth of Newport: My Lords, the Government are placing new duties on local authorities in terms of the anti-drugs strategy, and Public Health England, very rightly and admirably, is seeking to develop its contribution to the strategy ambitiously and appropriately. Will the Minister ask his right honourable friend the Secretary of State for Health to give a very strong moral lead, at least to urge local authorities not to reduce spending in this area, which is so crucial to the health and safety of young people in particular?

Lord Prior of Brampton: I will certainly have a word with my friend the Secretary of State for Health. Clearly the Government have an important role in this area; I will have a discussion with him and come back to my noble friend.

Lord Patel: My Lords, this is my first opportunity to ask the noble Lord a question and I welcome him to his new brief. If he were looking at the evidence-based delivery of services, the evidence shows that 40% of illnesses are related to lifestyle. If that is the case, why do we not have a national plan for public health and prevention of disease, rather than leaving it to local authorities, where it will vary?

Lord Prior of Brampton: The noble Lord raises an interesting point, which we may come back to in the debate later. Public health spending is divided into two: £3.2 billion is decentralised to local authorities and the remaining amount, some £2 billion, is retained by Public Health England—which does have a national plan, but it may be that the plan could be better articulated.

Security: State Procession
	 — 
	Question

Lord Wallace of Saltaire: To ask Her Majesty’s Government what assessment they have made of the potential security risks posed by converting former government buildings into privately owned hotels along the State Procession route between Buckingham Palace and the Palace of Westminster, including along Whitehall.

Lord Bridges of Headley: My Lords, the former government buildings to be converted into hotels along the state procession route are Admiralty Arch and the
	Old War Office. The freeholds remain under government ownership in perpetuity and continued oversight and security measures will be implemented as part of the commercial arrangements with the private sector. Long-term protocols and operating procedures are agreed and built into both schemes. The security and intelligence services and the Metropolitan Police are closely involved in this process.

Lord Wallace of Saltaire: My Lords, does the noble Lord recall that when President Bush made a state visit to London, the entire Whitehall area was cordoned off, including to Members of Parliament? Does he also recall that the IRA, from within the area of Whitehall, managed to mortar No. 10? Further, he will remember that the bombing of the Brighton hotel, which affected Mrs Thatcher and others, was placed in the hotel some time in advance of the incident? Do the security services intend to vet positively all the staff of these hotels; has that been agreed? Will the hotels be closed to all visitors during state visits or will the visitors be vetted as well?

Lord Bridges of Headley: The noble Lord has raised interesting questions based on his own experience. I have looked into the clauses of the leases for both the Old War Office and Admiralty Arch and I am satisfied that they allow for appropriate access for both security and ceremonial purposes. The hotels will employ their own staff, and while the Government have not insisted on security clearances for each member of staff, it is obviously in the hoteliers’ interests to take their security checks on their staff into consideration. Furthermore, I should point out that both the Metropolitan Police and the security services are very involved, as always, in ceremonial processions and major events, and will continue to be so to make sure that security is upheld.

Lord Foulkes of Cumnock: My Lords, this is privatisation gone mad. Does the noble Lord really think that selling off the Old War Office building, just up the road from the Cenotaph, to a private foreign company for use as a hotel and private apartments will not cause major security risks? Of course it will. There will be Remembrance Day services and the Queen coming to open Parliament; it is extremely dangerous. Surely he must think again.

Lord Bridges of Headley: My Lords, I would take the noble Lord’s advice a lot more seriously if his own party had not recommended that we sell Inn the Park, the Civil Service Club and Marlborough House at the last general election. However, putting that to one side, I also point out that once again the Labour Party seems to be in a state of sleep as regards the deficit, as the noble Lord, Lord Mandelson, seems to have suggested. We do actually need to bring down the deficit—

Noble Lords: Oh!

Lord Bridges of Headley: I am sorry that noble Lords shake their heads but, as my right honourable friend the Chancellor pointed out yesterday, we need to do it. Since 2010 the Government have generated £1.4 billion in land and building sales while the running costs of the estate have fallen by £647 million
	compared with 2009-10. Moreover we have done that while ensuring that security is upheld, as I have explained to the noble Lord.

Lord Lisvane: My Lords, as someone who sought to buy the Curtis Green building for parliamentary use rather than as a luxury hotel, I commend the noble Lord, Lord Wallace of Saltaire, for raising this issue. It is extremely important that a full formal CPNI security assessment is given to Ministers in the case of each building. I ask the Minister to bear in mind that many of these buildings are connected underground. I also ask him to ignore the siren voices which suggest that security can be assured simply by sealing tunnels. It cannot; ask anybody in Hatton Garden.

Lord Bridges of Headley: There are service ducts under many buildings for electricity, telecommunications and other services, and any security risks in relation to them, as with any other part of the buildings, have been assessed and taken into account in the sale of the leases. I need to repeat that the security agencies are involved in all disposals of government property and their advice is always taken into account.

Lord Reid of Cardowan: My Lords, I must say with some regret to the Minister, who has not long arrived in his post, that I thought his answer to my noble friend Lord Foulkes was not only unsatisfactory but bordering on the disgraceful. He said in his previous answer that it was in the interests of the new private owners to ensure security. National security is a matter for the Government, not for new private owners. As to the reduction of the deficit, while obviously we want to do that, if the cost of reducing the deficit by a couple of hundred million pounds is to put our national security—not to mention the monarch—at risk, it is not a price worth paying. Whichever Government made the decision, will he come back to the House with a more satisfactory answer as to the national security aspects of this particular sell-off?

Lord Bridges of Headley: I apologise if I have caused offence but I was being accused of privatisation. I would, however, beg to differ. I do not believe that these decisions have put the national security at risk and I have been assured that they have gone through the appropriate processes. The properties were designated surplus to requirements, following a thorough review which concluded that the buildings could not within the bounds of costs and internal planning be updated to deliver an acceptable, efficient standard of office accommodation for use in government. The commercial arrangements with the private sector allow for government to incorporate security measures, alongside the Metropolitan Police.

Lord Hamilton of Epsom: Has my noble friend denoted a massive security risk from the Royal Horseguards hotel, which is just round the corner from the Old War Office?

Lord Bridges of Headley: My Lords, I cannot comment on particular aspects of security but I assure your Lordships that all matters of security within the Westminster area are always taken under review.

Lord Hunt of Kings Heath: My Lords, will the noble Lord refer this matter to the appropriate Joint Select Committee of both Houses, which looks into these matters? I think that would give a great deal more confidence.

Lord Bridges of Headley: My Lords, let me take that concept away with me. I have looked into this matter over the last few days and I am assured that the relevant security matters have been addressed, and that we have balanced those matters with the need to deliver savings in government.

Lord West of Spithead: My Lords, on a slightly less serious point, are the new owners responsible for ensuring that all the various flag-staffs, with flags and all the things that are flown on state occasions, will be dealt with correctly? There is a strict format for this and a cost involved. Is that their liability?

Lord Bridges of Headley: The flags for ceremonial events will remain on Admiralty Arch. This is a provision in the lease arrangements. Should the hotel wish to use its own flags, a proposal will have to be made to government to consider how that will be done.

Consumer Protection: Secondary Ticketing
	 — 
	Question

Lord Clement-Jones: To ask Her Majesty’s Government when they intend to commence the review of the consumer protection measures for the secondary ticketing market under section 94 of the Consumer Rights Act 2015; and who will undertake it.

Baroness Neville-Rolfe: My Lords, work on appointing the chair and expert group is well advanced and the review will proceed once this and the terms of reference are finalised. We are aware of our statutory obligation to publish a report on its findings by 26 May 2016.

Lord Clement-Jones: My Lords, I thank the Minister for that reply but ticket fraud continues to soar this summer. Circle Tickets has defrauded hundreds of music fans just this June while the RFU reports zero compliance with the Act for World Cup tickets, so the problem remains acute. This review is enshrined in statute as a result of the efforts of the noble Lord, Lord Moynihan, and others only recently. We are now two months out from the general election. When will this review start, will BIS or the DCMS oversee it and what will its scope be?

Baroness Neville-Rolfe: My Lords, as I have said, we will publish details of the review shortly. I share the noble Lord’s disappointment on the enforcement side and, prompted by his Question, I spoke to the City of London Police only last week. I was reassured about some of the actions it is taking, both on its own and with the cultural and sporting bodies, for the important events of this summer. As the noble Lord
	will know, May through to July is the peak period so there will be more cases, but Action Fraud is on to the job.

Lord Moynihan: My Lords, I thank my noble friend for the work that she has undertaken on this subject. Can she assure the House that the review committee members will be provided with a clear legal opinion as to exactly what information can be included on tickets to sport and musical events, within the interpretation of the EU consumer rights directive?

Baroness Neville-Rolfe: I thank my noble friend for all he has done to move forward the consumer offer in this important area. I can confirm that the review will assess the current law, including changes we made in the Consumer Rights Act as a result of work in this House, and any surrounding law, which would rightly include any EU provisions.

Lord Stevenson of Balmacara: My Lords, further to that response, which I welcome, can the Minister spell out a little more how the review will operate, as information on that is still not available? It will presumably receive evidence. If it does, will it take oral and well as written testimony and, if that evidence is provided, will it be published so that we can all look at it?

Baroness Neville-Rolfe: I am grateful to the noble Lord for his questions. We have debated some of these points before. The chair will need to take a view on exactly how they run things. Clearly, the idea of a review is to have a wide range of evidence, and I think we will come back to the House on exactly how we organise that once we announce the review and the precise terms of reference. We have a short time for this, but it is good to have a focused review with an end date. We also need experience of how the new arrangements are working, as they only came into effect on 27 May. The review will be able to look at the summer of joy—the Ashes, the World Cup and Wimbledon, which is on at the moment—and see how the arrangements are working.

Women in the Workplace
	 — 
	Question

Baroness Thornton: To ask Her Majesty’s Government what assessment they have made of the European Institute for Gender Equality’s 2015 index; and what steps they are taking to improve women’s quality of employment, and their participation and integration in the workplace.

Baroness Williams of Trafford: My Lords, the gender equality index provides a measure of gender equality across the EU. The UK’s overall score in the 2015 index is above the EU average and based on data collected in 2012. We continue to make good progress, particularly in the domain of work, with more women in work than ever
	before, more women-led businesses and a gender pay gap that is the lowest ever and has been eliminated for full-time workers under 40.

Baroness Thornton: I thank the Minister for that Answer, but the Government should surely be concerned that the EU Institute for Gender Equality figures show that progress on gender equality in the UK has gone backwards in key areas. Yesterday the Chancellor had the gall to talk about equality for women in his speech but his Budget is going to hit women more than twice as hard as men. Where is the equality in the fact that, according to the Commons Library, 70% of the £34 billion in welfare savings in the Budget yesterday will come from women? What impact does the Minister think this will have on women and their participation in the workforce? Will the Minister commit to monitoring and publishing the impact of the Budget on women and work?

Baroness Williams of Trafford: My Lords, women will be able to avail themselves of the new living wage, which will help take women out of state dependency and into a very decent wage for the first time. There will, of course, be a tax-free allowance of £11,000 of which women will be able to avail themselves; an increase in free nursery provision from 15 hours; and an extended right to flexible working. I think that this Government have done more for women than any other Government in living memory.

Earl Attlee: My Lords, did my noble friend notice the article in the Economist several months ago that urged a great deal of caution when using these rankings, because the results are greatly influenced by the methodology used?

Baroness Williams of Trafford: My noble friend is absolutely right that methodologies vary in different analyses. His comment also touches on the fact that these figures are quite often old ones. Those referred to in the noble Baroness’s Question go back to 2012, and much progress has been made since then.

Lord Kinnock: In introducing the new living wage, the Chancellor referred to the Resolution Foundation with commendation, and rightly so. Is the Minister aware that the Resolution Foundation made it clear that the living wage could be £9 an hour if working tax credits were maintained, but that without working tax credits it would need to be £12? Are we going to hear an announcement to that effect?

Baroness Williams of Trafford: My Lords, the Chancellor said yesterday that the living wage should mitigate the reduction in tax credits.

Baroness Smith of Basildon: My Lords, the noble Baroness said that women are better off under her Government than any other Government, yet all the independent analyses show that a woman who is a lone parent with two children and works earning the minimum wage—the living wage, as the noble Baroness now calls it—would gain around £400 from these changes but lose more than twice that from the other
	changes that the Government are bringing to tax credits. How does that help working parents stay in work? How does it benefit women?

Baroness Williams of Trafford: My Lords, the living wage helps everybody, including women, get a decent wage for going out to work. Free childcare certainly helps women who want to go out to work. Also, taking women out of tax for the first £11,000 certainly helps women get back to work.

Lord Dholakia: My Lords, how are gender equality issues addressed in government departments? Is there an adequate system of monitoring and, if so, how are results published? If the results are not favourable, is it not time to invite the Equality and Human Rights Commission to audit to see why women’s representation does not reflect their presence in the community?

Baroness Williams of Trafford: The noble Lord asks a good question. The ONS monitors gender pay differences by department. I am very pleased that, in my own department, four out of seven of the senior executives are women, including the Permanent Secretary.

Lord Hamilton of Epsom: Is there not serious evidence of inequality in that a far higher percentage of women are employed than men?

Baroness Williams of Trafford: In other words, we are going in the opposite direction. I think it is only a good thing that more women are employed in senior positions. This Government have made a real effort in that direction.

Baroness McIntosh of Hudnall: My Lords, would the noble Baroness have another go at answering the question from my noble friend Lord Kinnock? She implied that in some way the £9 living wage to which the Government aspire will mitigate the losses that people incur in the loss of tax credits, but she did not answer his question about the evidence which the Resolution Foundation put forward that, in fact, the needful figure would be £12. What is her answer to that question?

Baroness Williams of Trafford: I apologise as I only took one of the questions from the noble Lord. I have not read the report from the Resolution Foundation. I am happy to respond in writing.

Lord Lea of Crondall: Are the Government relying on a magic wand to introduce the living wage, or has the legislation that will be required been thought through, and when will it be announced?

Baroness Williams of Trafford: The living wage has been announced. I am sure that detail of its phase-in will be announced in due course.

Lord Beecham: My Lords, how will the imposition of the proposed increase of around £70 a week in council rents for households with a joint income of £40,000 a year in London or £30,000 elsewhere help to improve equality of employment and participation of women in the workforce?

Baroness Williams of Trafford: My Lords, the introduction of those rents recognises that people on higher salaries should be able to play their part in contributing to rents.

Baroness Howarth of Breckland: My Lords, the noble Baroness mentioned free childcare. As I understand it, free childcare will not come into operation until 2017 for those who are working the extra hours. How will that help families immediately, who will find that they are extremely short in a working week?

Baroness Williams of Trafford: My Lords, free childcare is already in operation. Its extension will be in operation in due course.

Baroness Smith of Basildon: My Lords, the noble Baroness said in answer to my noble friend that those on higher incomes should pay a higher rent, and she quoted the figure of £30,000 income for those outside London. That is the correct figure; we have read the figures. However, is she aware that that could be the joint income of two people on a basic living wage of £15,000 a year? Does she think that £15,000 a year is a higher income?

Baroness Williams of Trafford: My Lords, I did not quote that figure; it was the noble Lord, Lord Beecham. However, I recognise that those are the figures. This Government must balance the reduction of the deficit and growing the economy. Everyone has to play their part.

Lord Brooke of Sutton Mandeville: My Lords, does my noble friend recall that the only occasion on which the wartime coalition Government were defeated on the Floor of the House of Commons between 1939 and 1945 was on an amendment to Mr Butler’s Education Act 1944 to the effect that, after the war, women teachers should be paid as much as male teachers? That amendment was moved by the late noble kinsman of my noble friend Lord Eccles. It was carried by one vote, but it was carried by Conservative votes.

Baroness Williams of Trafford: My noble friend will appreciate that I do not remember it, but he demonstrates, as always, a very good point.

Baroness Walmsley: My Lords, following the question from the noble Baroness, Lady Howarth, will the Minister say why the Government have pushed the introduction of tax-free childcare on by another year? Surely the watchword of this Budget was not “a Budget for security” but “jam tomorrow for hard-working families with children”.

Baroness Williams of Trafford: My Lords, I think noble Lords will agree that it is certainly going in the right direction.

Baroness Thornton: Will the Minister answer the question that I asked about monitoring? Since she and I disagree about the impact on women and working women, it is very important that the Government monitor and publish an impact statement on the effect of this Budget on women and work.

Baroness Williams of Trafford: My Lords, as I said, the ONS publishes figures on the gender pay gap in the Civil Service. We are tasking companies with more than 250 employees to publish their gender pay gaps.

Energy Bill [HL]
	 — 
	First Reading

A Bill to make provision about the Oil and Gas Authority and its functions; to make provision about fees in respect of activities relating to oil, gas, carbon dioxide and pipelines; to make provision about wind power; and for connected purposes.
	The Bill was introduced by Lord Bourne of Aberystwyth, read a first time and ordered to be printed.

Business of the House
	 — 
	Timing of Debates

Moved by Baroness Stowell of Beeston
	That the debates on the motions in the names of Lord Patel and Lord Alton of Liverpool set down for today shall each be limited to 2½ hours.
	Motion agreed.

Consolidation etc. Bills Committee
	 — 
	Membership Motion

Moved by The Chairman of Committees
	That Baroness Andrews be appointed a member of the Committee to join with a Committee of the Commons as the Joint Committee on Consolidation etc. Bills.
	Motion agreed.

Equality Act 2010 and Disability Committee
	 — 
	Membership Motion

Moved by The Chairman of Committees
	That Lord Foster of Bishop Auckland be appointed a member of the Select Committee in place of Baroness Wilkins, resigned.
	Motion agreed.

House Committee
	 — 
	Membership Motion

Moved by The Chairman of Committees
	That Baroness Manzoor be appointed a member of the Select Committee.
	Motion agreed.

Palace of Westminster Committee
	 — 
	Motion to Approve

Moved by Baroness Stowell of Beeston
	That it is expedient that a joint committee of Lords and Commons be appointed to consider and report on the restoration and renewal of the Palace of Westminster in the light of the Independent Options Appraisal commissioned by the House Committee and the House of Commons Commission.

Lord Richard: My Lords, I think the House would feel that it is terribly important that there should be equality of representation on this committee between both Houses. That is true not only in terms of the number of people who are involved on both sides but in the offices that some of them will represent. I have heard it said that the Chairman of Committees will not be represented in the Lords representation on this Joint Committee. As I understand it, he performs in this House functions similar to those performed by an official in the other place who will be on the committee. In those circumstances, there seems to be a disparity between the representation of the two Houses. If that is so, will the Leader of the House undertake to make sure that something is done about it?

Lord Foulkes of Cumnock: My Lords, this is a matter of major importance and of potentially huge public expenditure. As far as I can recall, we have not had the opportunity of debating it in this House yet. I went to a presentation in Portcullis House, as did some other Members, organised by the Clerk of the Parliaments and the Clerk of the House of Commons. I must say that I found it totally inadequate: there were questions that could not be answered and the presentation was not clear. We need more information about exactly what options are being proposed.
	I ask three things from the Leader of the House. First, to repeat the point made by my noble friend, representation should be equal between this House and the other place. A decision was made about the education centre, which has major implications for us, but we were not able to play any part in it—it was made by the House of Commons and forced upon us, yet the centre is effectively just outside our back door and will have a huge effect on us. Can we have an assurance that we will have equal representation on the committee?
	Secondly, can we get an assurance that before any decision is taken that will affect expenditure and the workings of this House there will be a full debate in this House, and that no decision will be made without such a debate? Thirdly, I ask the noble Baroness to make it clear that the Joint Committee will consider all the options for dealing with this matter, not just those that have been put forward so far as a preferred option or preferred options. All of them should be looked at properly and thoroughly by the committee. This is a matter of great importance, and I find it very strange that it was almost put through on the nod.

Lord Grocott: To follow on from my noble friend’s point, on a related matter, he is quite right that this is an issue that affects both Houses of Parliament
	but there are many other issues, one of which is highly relevant, pertinent and newsworthy at the moment: English votes on English laws. It has been suggested that the rules relating to that could be made in the Commons without any proper joint consultation with Members of this House. There should be at least a Joint Committee of some sort to look at the implications for both Chambers of changes of this magnitude.
	I do not use the word “disgrace” lightly, but it is a disgrace that we are making fundamental constitutional changes by an order in the Commons without any reference to us whatever. Changing the legislative process, in which we are intimately involved, unilaterally in one House without any consultation, let alone agreement, between the two Houses is unacceptable. I put it to the noble Baroness respectfully that she, as Leader of the House, has a duty to those of us here, particularly the Scots, not to allow our rights to be in any way diminished by any changes in the constitutional arrangements—at least, not without both Houses being fully involved.

Earl Attlee: My Lords, returning to the subject of the debate, I urge my noble friend the Leader to carefully consider the need for full debate in your Lordships’ House before the committee does too much work.

Lord Lea of Crondall: My Lords, is the logic of what is being said not so much whether or not this or that decision is the correct one but that this needs to be a two-tier consultation exercise? The noble Baroness the Leader may care to say a bit more about the process of selecting who goes on to the Joint Committee, as has been said, but there are also some leading questions about the 40-year impact and so on that surely need to be brought back to the House for people to be able to comment on, when they have been considered more systematically by the Joint Committee, before final decisions are taken. It should not just be a question of saying yes or no to a report from a Joint Committee.

Baroness Stowell of Beeston: I am grateful to all noble Lords for the points that have been made in this short debate. I shall address the questions that have been put. First, on the membership of the committee, the Motion today sets the wheels in motion for a committee to be established. Membership of the committee is not yet finalised. I take on board the point made by the noble Lord, Lord Richard, about the quality of representation from this House and indeed its equality. We will put together a strong team to represent the interests of this House. Clearly, once I have had confirmation from the Commons of which people it intends to field on the committee, that will be reflected on before we finalise the membership of the committee as regards its representation from here.
	On the way in which we proceed, there will certainly be equality in numbers on that committee, which will be a Joint Committee of both Houses. The intention is that the Joint Committee will be co-chaired by myself and the leader of the House of Commons, primarily so that we ensure—as I said when this matter was raised here a few months ago—that this House is in no
	way considered in any way subordinate when we discuss matters of this kind. I very much see it as my responsibility as Leader of this House to ensure that the situation that the noble Lord, Lord Foulkes, referred to with regard to the education centre is not repeated.
	Once the committee is established, clearly we will want to interrogate very thoroughly the report that was produced by the independent consultants and published a couple of weeks ago. Ultimately, it will be for both Houses of Parliament to take the decision on the way forward on restoration and renewal, and I will certainly want to consider carefully the process between the committee being set up and its work starting, to the point at which we make a decision by way of a full debate and Division in each House. It is of course important that I and all others who sit on that committee from this House can properly understand and are able to take into account the views of Members as we carry out our work. Therefore I hope that I can give noble Lords the reassurance they are looking for in responding to those points.
	On the point raised by the noble Lord, Lord Grocott, on English votes for English laws, I do not intend to divert from the topic of this Motion, but I refer him to the Statement I repeated in your Lordships’ House last Thursday, and to the points I made in response to the questions in that debate. The key point was that with regard to any decisions made in the House of Commons to change their procedures, whatever happens down there will not affect the authority or the processes in this House. However, the noble Lord, Lord Butler, has secured a Question for Short Debate next Thursday, and no doubt we will be able to discuss this matter further at that time.

Baroness Smith of Basildon: My Lords, on a point of clarity with regard to the first issue of the Joint Committee of the Lords and Commons, my understanding, from all the conversations I have had with the noble Baroness the Leader of the House, is that there will be completely equal representation between both Houses. I think that she has heard the mood of the House—that is what this House expects. I think she said that that was likely, but she did not give the guarantee that the House is seeking. Can I therefore press her, because that is my understanding of the present situation anyway, to give a guarantee that there will be equal representation between both Houses?
	On the noble Baroness’s second point, in which she responded to my noble friend Lord Grocott, as much as we welcome the QSD in the name of the noble Lord, Lord Butler, next week on 16 July, that does not replace the need for a proper debate on the proposals for English votes for English laws, which impact on the work of your Lordships’ House. It is all very well for the noble Baroness to say, “We are not affected by it”, but we are. It affects how legislation is conducted in Parliament, and we are part of that process. I know that when she responded to the debate on the Statement the Government made last week she rejected the notion, but she will have heard that noble Lords across the House are very concerned at the lack of debate in this House on that issue, and I urge her to reconsider. It is the view of the Official Opposition and, I think, of other noble Lords around this House,
	that there should be a full debate, perhaps on a Motion that can be divided on as well. To deny this House the opportunity to debate this in government time is totally unacceptable.

Lord Butler of Brockwell: Further to the point made by the Leader of the Opposition, I understand that in another place the Government have decided not to go ahead with the changes to Standing Orders next week but to have a two-day debate on them. Does that not strengthen the case for there also being a full debate in this House, in addition to the Question for Short Debate?

Baroness Stowell of Beeston: Coming back to the topic of this Motion, I make it clear to the noble Baroness and to the House that it has been my view that the membership of the restoration and renewal Joint Committee should be equal in numbers and in approach in terms of this House and the other place. I am just waiting for the House of Commons to confirm its approach before we finalise our own because I am trying to achieve exactly that aim—making sure that there is a proper balance in the way that the Joint Committee is formed. I hope that that gives the noble Baroness and the House the assurance that they are looking for. Therefore, we will be equally represented in number, and I might even suggest to your Lordships that the team of members from this House will be more powerful and more authoritative, because, quite frankly, that is what I think we are.
	I note what the noble Lord, Lord Butler, said about the decision in the House of Commons regarding English votes for English laws, but I say to him, as I say to the noble Baroness and to the House as a whole, that the House of Commons is debating changes to its Standing Orders.

Lord Foulkes of Cumnock: That will affect us.

Baroness Stowell of Beeston: I note that a noble Lord said from a sedentary position that that will affect us. However, the processes and procedures of our House will not be affected by any changes to the Standing Orders in the other place.
	Motion agreed.

Financial Assistance to Opposition Parties and the Convenor of the Cross-Bench Peers
	 — 
	Motion to Approve

Moved by Baroness Stowell of Beeston
	That, in the opinion of this House—
	(a) with effect from 8 May 2015, the resolution of the House of 24 June 2010 (financial assistance to opposition parties) shall cease to have effect; and the resolution of the House of 30 July 2002 (financial assistance to opposition parties) shall have effect from 8 May 2015 as it would have done if the resolution of the House of 24 June 2010 had not been passed, and
	(b) with effect from 1 April 2015 the resolution of the House of 30 July 2002 shall have effect as if paragraph (2)(a) provided for £87,761 to be the maximum amount of financial assistance which may be given to the Convenor of the Cross-Bench Peers for the year beginning with 1 April 2015; and paragraph (2)(b) of that resolution shall apply in relation to each subsequent year accordingly.

Baroness Stowell of Beeston: My Lords, it may be helpful if I explain the background to this Motion. As noble Lords will know, since 1996 this House has agreed to provide a sum of money to be set aside for the two main opposition parties in your Lordships’ House and, since 1999, has provided the same for the Convenor of the Cross Benches.
	As your Lordships may also recall, in June 2010 we put into abeyance the funding available to the second-largest opposition party, because the Liberal Democrats formed part of the coalition Government following the general election. Now, the coalition Government are no more. The first limb of this Motion recognises that fact and returns us to the situation as it was before the 2010 Parliament, allowing the Liberal Democrat group to draw down funds to discharge its responsibilities as the second-largest opposition party in this House.
	The effect of the second limb of the Motion is to adjust the amount of funding available to the Convenor of the Cross Benches to provide the resources needed for him to operate an office with two full-time members of staff. The Motion is silent on the funding available to the Official Opposition. I should say for clarity that that is because the funding arrangements for Her Majesty’s Official Opposition on the Labour Benches remain unchanged.
	Overall, the two limbs of the Motion seek to allow this House to continue to undertake the important work that it is here to do, and I am pleased to have worked constructively with the leaders of both main opposition parties and the Convenor in bringing them forward. I beg to move.

Lord Pearson of Rannoch: My Lords, I have given the noble Baroness the Leader of the House notice of this intervention, which arises because I understand that this Motion, if we pass it, will give taxpayers’ money—Cranborne money, I think it is called—to the Liberal Democrats to help them to run their affairs in your Lordships’ House and perhaps elsewhere. If so, I suggest that your Lordships do not pass it until we have agreed an appropriate award of finance for my party, the UK Independence Party.
	I ask this against the background of the admittedly unwise policy of the previous coalition Government, which I understand was inspired by the Liberal Democrats and to which I gather they still adhere. That committed the Prime Minister to recommend new Peers to Her Majesty in proportion to the votes cast in the previous general election. That policy would have given the Liberal Democrats some 43 Peers in your Lordships’ House, from their 8% share of the votes cast in May. In fact, they enjoy 102 Peers. Should this situation not be set against UKIP’s present three Peers, from our 13% share of that vote? Under the previous Liberal
	Democrat policy, we should have 69—so they have 59 more Peers than they should, whereas we have 66 fewer. I trust your Lordships will agree that we should have at least some Cranborne money to help us with our work here.
	Noble Lords may be aware that I am in correspondence with the Prime Minister to adjust the present injustice by recommending a number of UKIP Peers to Her Majesty. I trust that we can revisit this matter, if and when that happens. I am not entirely confident that we will get a decent number of Peers, but surely masters cannot go on being so unfair to Molesworth for ever—or can they?
	While I am at it, since 185 Peers joined us in the last Parliament, with none for UKIP, and we are already somewhat cramped for space, would not one sensible solution be for, say, 30 Liberal Democrat Peers to stand down? That would free up a share of Cranborne money for UKIP and give us all rather more space. Would not that kill two birds with one stone? I look forward to the Minister’s reply.

Lord Dholakia: My Lords, if I may, I will respond very briefly. I do not think that the matter relates to how many Liberal Democrats are here. The fact remains that there are almost 102 Liberal Democrats, which has been recognised by the noble Baroness the Lord Privy Seal in the resolution that she has put before us. The intention is that we would perform as the second largest opposition party in this Chamber and, accordingly, we welcome the contribution being given to us as part of the Cranborne money.

Baroness Stowell of Beeston: I am grateful to the noble Lord, Lord Pearson, for giving me notice of his intention to contribute on this Motion. He makes his presence felt in your Lordships’ House, and he and his UKIP colleagues are an important part of the membership of this House. However, as I think he will know, the Cranborne money is provided for opposition parties in this House on a formula that is very different from the way in which Short money is provided in the House of Commons. It is very much based on the size of the opposition parties in this House and not reflective in any way of popular vote share or seats in another place. He may wish that matters were different in this House when it comes to numbers—I recognise that his view is widely shared; I made that point when responding to questions last week—but we have to deal with the situation that we find ourselves in. Following the appropriate discussions in the usual channels, this Motion returns the level of funding for the second-largest opposition party in this House to what it was, in proportionate terms, before 2010.
	I am not going to comment on the noble Lord’s wish that there be more UKIP Members in this House. The Cranborne money is provided for the opposition parties to operate a Front Bench. I am not sure that the noble Lord, as effective as he is, is in a position to provide the range of posts that might lead UKIP to become a significant strength in terms of a shadow Front Bench in this House, but I am grateful to him for all that he does, even though his numbers are limited at this time.

Lord Pearson of Rannoch: My Lords, I am most grateful to the noble Baroness. The answer to her last point is that that rather depends on how many UKIP Peers arrive in this place and who they are. I simply make the point that I do not think that it is right that the first and second opposition parties should have some financial assistance here. So should the Greens, so should we all—maybe just a little; maybe just to pay for one tiny, little secretary. That would be very helpful.

Baroness Stowell of Beeston: As I have said, the point of Cranborne funding when it was set up was to enable the main opposition parties, both the Official Opposition and the second-largest opposition party, to operate a Front Bench. It is not based on numbers. The proportion provided to either of those parties is not affected by their electoral performance in different elections. After the 2005 election, when the Liberal Democrats—I am not sure whether they would like me to remind them of this—did better then than they did in 2015, their proportion was not affected. The Cross Bench receives a smaller allocation in order for it to have some secretarial support but, clearly, if we were to base it on numbers, we would see that the Cross Bench is larger than the Liberal Democrats. The way in which the money is divided shows the purpose behind it in the first place.
	Motion agreed.

National Health Service: Sustainability
	 — 
	Motion to Take Note

Moved by Lord Patel
	That this House takes note of the sustainability of the National Health Service as a public service free at the point of need.

Lord Patel: My Lords, it is a great pleasure to open this debate. I was a little concerned that, because of today’s Tube strike, our numbers might be devastated, but I am pleased to see that they are not—too much.
	I am grateful to all noble Lords who will be taking part, many with a long experience in health. I am particularly delighted to see the noble Lord, Lord Mawhinney, in his seat and taking part in the debate.
	Health is determined by a complex interaction of individual characteristics; lifestyle; and physical, social and economic environment—that is, your genetics, your epigenetics and your lifestyle. To keep the citizens of a nation healthy needs a strategy with appropriate policies and resources to address all these interactions. A system that keeps the citizens of a nation healthy needs to be a partnership of individuals, the wider community and the state.
	While the state has a role in all aspects of health—prevention, healthcare and social care—the limits of that role have to be clearly defined and can be arrived at only by a wide consensus that includes the public, wider stakeholders and the state, each recognising and accepting their responsibility. What we have today in the NHS is primarily a service that treats patients when they are ill—some say a “sickness service”. It is
	clear that, when it comes to prevention, both the state and the individual need to do more—and I would say that the individual has a greater responsibility.
	The consequences of not tackling disease prevention are grim, in terms both of individual misery and state resources. It is also clear that a changing demography—with a population increase—and increasing life expectancy will lead to an increase in the number of people needing social care.
	The association of lifestyle with disease is well known, and yet in the UK 70% of the population is inactive, and 26% is obese, which will increase to 40% by 2025. This will result in 4 million people with diabetes. Some 70% of the population have poor diet and 21% smoke. Some 27% of men and 18% of women drink alcohol well above the safe limits. Some 40% of disease is related to lifestyle, including cancers and Alzheimer’s. The scale of preventable illness is staggering. An effective national plan—dare I say, which we do not have—for preventable illness could reduce mortality by 25% by 2025. Otherwise, the impact of lifestyle-related diseases and changing demography will put an even greater strain on resources.
	The projected scenario is that there will be, apart from diabetes, 2.9 million people living with a long-term condition and 4 million living with cancer. By 2026, 1.4 million people will have dementia, costing about £3.5 billion a year. Some 4.5 million people will need help with daily living and 17 million people will have arthritis and other joint conditions. Providing social care will take a greater proportion of resources. The cost of care alone could consume 2.5% of GDP. A survey that showed that only 26% of older people think that they need to make provision for their social care demonstrates a lack of public concern and involvement.
	I now come to the current state of the NHS: the care part of the health equation. The founding of the NHS, 67 years and four days ago, was heralded as a great piece of social legislation—and so it was. The public’s love affair with it has not diminished. At its launch, the annual budget was £280 million. In 2013-14, the NHS spend was approximately £116 billion—close to 9% of GDP—and the pressure on resources continues. The demand for care is not diminishing. Financial problems are now endemic among NHS providers. Even the previously best-performing trusts are heading towards deficit. Some 89% of trusts are forecasting deficits, faced with increasing demands, cuts in tariffs and the withdrawal of performance payments. Provider deficit could top £20 billion this year. The FiveYear Forward View of Simon Stevens was a commendable document that I will return to later because it tries to address some of these issues. It predicts a need for extra funding of £8 billion a year by 2020-21. I know that the Chancellor yesterday said that he will fund it by £10 billion—but he included £2 billion already given to the NHS.
	At the same time, the service has delivered already in the last Parliament £20 billion-worth of efficiency savings, mostly through limiting staff salaries, cutting administration costs and the lucky break of blockbuster drugs coming off patent. An ambition to deliver further
	efficiency savings of £22 billion a year by 2020-21 through productivity gains of 2% to 3%, if it can be achieved, will be challenging. Further reducing staff salaries and holding pay to 1% for the next four years, as announced yesterday, and reducing the price paid for treatment is an option likely to lead to a further decrease in morale and less commitment from staff, leading to poorer-quality care, poorer outcomes and, dare I say, less likelihood of getting the productivity gains proposed.
	Historically, the NHS has never achieved productivity gains above 0.4% year on year. Achieving productivity gains of 1.5% will result in a shortfall of £16 billion; there will be a £21 billion shortfall if the gains are only 0.8%. In this scenario, the NHS will need an annual budget of nearly £200 billion by 2030 and one-fifth of the nation’s entire wealth by 2060.
	The current financial pressures are despite more than 20 major reorganisations and policy changes, mostly to cut costs, over the past 20 years—and these continue. Most recently, further policies to cut costs include: the reversal of safe nurse-to-patient ratios; the removal of some clinical targets; reducing the cost of agency nurses; and reducing the cost of having consultants and the pay of senior managers. The recent Carter report addresses efficiency and productivity gains that could—I use the word “could” because that is what the document says—save £5 billion in procurement per year. We have had three previous reports on procurement in the NHS.
	Not only do we have financial pressures but the performance of the NHS in terms of outcomes is not good. Although the NHS is rated very highly by the Commonwealth Fund for several parameters—no doubt the Minister will remind me about that—it is also rated second from bottom for avoidable deaths. Recent similar findings have been reported in a Health Foundation report for cancers, vascular disease and lung disease. There are 25,000 excess deaths associated with diabetes and 2,000 child deaths can be avoided. There is great variation in care throughout the country.
	Primary care does not fare any better, with long waits for appointments in some areas, late diagnoses leading to an increased number of deaths, and a dwindling workforce. It is difficult to see how a seven-day service in both the primary and acute sectors can be delivered without higher costs, with patients with long-term conditions resorting to attendance at A&E because of the lack of community care. The separation of community care from hospital-based services and social care inhibits integration, makes the delivery system weak and fragmented, and thwarts innovation in care. The NHS has never been great at innovating for service delivery. While I accept that not all is bad in the NHS—we must not throw away all the good things that it has—the system as a whole is not performing well.
	Is the current system sustainable? There are some who would say, “Yes, but it needs more resources”. Others would say, “Yes, if only we can produce the efficiency and productivity that is there to be had. It needs to improve”—there is room to do so, I agree—“and cutting waste will solve some of the problems”. Others feel that we need to look for a new settlement, for more durable, long-term solutions that will keep the
	citizens of this nation healthy for as long as possible in their life—a new system where prevention, care and social care are a continuum; in which the individual, the community and the state have a commitment and a shared responsibility; where people with long-term conditions are able to manage their own illnesses; where individuals plan for their own health and are helped to plan for their social care if they need it; and which can adopt new ways of care and embrace innovation.
	The history of the past two and a half decades tells us that political parties will continue to manage the health service according to their ideology—managing scandals and giving a bit more money—but with no long-term planning as there will be no political consensus. We need a wider dialogue with the public, stakeholders and politicians to explore a new settlement, a new way of delivering care and social care, and, above all, a strategy to prevent illness. We need a national consensus that recognises and accepts that individuals, communities—including employers—and the state have a role in health and contributing to it. To do this, we need an independent national commission that is free to look at all the issues, not just at financing the service. The current system is not sustainable. I have no doubt that changes will be brought about. If we persist in the same way as we have done for the last 20 years we will see a gradual shift to a two-tier system: those who can pay will get care; those who cannot will not. The variations in care will get wider.
	I hope that today’s debate can start a wider conversation. If that happens, I, for one, can imagine that the logical conclusion will be that we need an independent commission to explore a new way, a new settlement for health that is compassionate and caring, and where all citizens have a stake to contribute to make their life healthier. I think that Simon Stevens’ FiveYear ForwardView is a good strategy and a good point on which we can build.
	I have two simple questions for the Minister. First, does he agree that the current system is unsustainable? Secondly, does he agree that all I have said about current and future scenarios is true? I beg to move.

Lord Fowler: My Lords, first, I congratulate most sincerely the noble Lord, Lord Patel, on his speech and on the debate. He talked about exactly the kind of issues that we should be talking about, and which the public generally should be talking about. As he might imagine, what he said about a commission was music to my ears. We should take note of what he also said about the financial problems in the NHS, which are endemic.
	It is spending not just today about which we should be concerned—although I congratulate the Chancellor of the Exchequer on the resources he has made available—but spending in the future. For far too long, there has been a political preoccupation with structures and organisations to the extent that today there cannot be one person in 100 who could say how the National Health Service is actually organised. That includes quite a number of people working in the health service.
	I hope that the debate can now change and tackle the obvious problems that we face. The principal one is clear. We all want a health service free at the point of delivery so that people are not denied healthcare because of a lack of income. That is basic. However, we also know that the costs of the health service are increasing because of medical advance, rising expectations and an increasing elderly population. The question is: how can we finance this increasing demand? That is an appropriate question on the day after the Budget. It is also appropriate because it seems to me that the dangers are clear. We are funding health through general taxation but what is crystal clear is the pressure on public spending. That pressure will continue. At the same time we find that large areas of public spending are exempt from economies and reductions. Health, of course, is one of those and 60% of social security spending is another.
	The Government are forced to look at the areas not protected for reductions, such as the 40% of the social security budget. It is for such reasons that they are driven into eccentric policies, such as putting the costs of the over-75s television licence fee on to the BBC. I say “eccentric” although I could put it rather higher than that—I might on Tuesday when we debate this issue. The fact that the Government are driven to such policies shows just how uncertain the position is. It raises the question of whether public spending will be sufficient to meet the emerging needs in the long term, and whether we can keep going on the same basis and keep going back to the same departments to make economies.
	I raised that issue in the Queen’s speech debate, but received what I term a dusty ministerial reply from the first Conservative Government for nearly 20 years, which was that Derek Wanless had gone into all these issues a few years ago. I find it slightly odd that the Government should rely on a report commissioned by Gordon Brown, published in 2002 and prepared by Derek Wanless and the health trends review team of Her Majesty’s Treasury. It is particularly odd when you consider that the report looked at the resources required, but said quite explicitly:
	“Its remit was not to look at how those resources should be financed”.
	It also said that there should be further and regular reviews.
	To my mind—and I very much echo what the noble Lord, Lord Patel, said—what is required at the start of the new Parliament is a thorough, independent and authoritative review of the financial pressures that the health service will come under, and at the same time to set out the options for financing healthcare. We may find that funding it out of general taxation is the best and most cost-effective method—I certainly argued that it was a cost-effective service when I was Secretary of State—but we cannot have a sensible debate on the way forward without examining the other issues. We could have a ring-fenced health tax, or look at a potential system of health insurance. We should explore the part that charges could play: I always found it extraordinary that, for example, prescription charges caused so much upset, given that about 70% were prescribed absolutely free. We should look at economies that can be made in the drugs bill and a whole range of other things.
	These are difficult questions, particularly given how health is exploited as a political issue—any change is alleged to mean the destruction of the heath service as we know it—but they are options that should be explored. That is why I believe that a royal commission, made up of independent members and working quite openly, would be the way forward. It would look at the resources needed to deliver a high-quality health service that is free at the point of delivery, but also examine how those resources should be financed. I am sure that many will say that this cannot be done and that it is politically too difficult. Frankly, however, we have an exceptional opportunity, at the beginning of a Parliament, to mount a thorough and open investigation into the financial pressures that the health service is and will be under and how they can be met. That would be supported by those who are concerned about not just the state of the health service today, but its future over the coming years. I very much hope that this is a challenge the Government will not duck.

Lord Turnberg: My Lords, I, too, congratulate the noble Lord, Lord Patel, on introducing this important debate in such a powerful and impressive way. I, too, resonate very much with the idea of a royal commission. Indeed, I suggested it some time ago in a previous debate.
	When the noble Earl, Lord Howe, was Health Minister he must have got used to me banging on about the parlous state of NHS finances, so I see no reason why I should not continue that theme with his esteemed successor, the noble Lord, Lord Prior. But I say at the outset that I do not go along with the “black hole” or the “bottomless pit” theory that we will never be able to fund the NHS adequately. The bottomless pit argument is faulty because, while we may not be able to afford everything that everyone wants, we can and should afford what they need. That is, we can afford a service that is widely regarded as satisfactory and which can meet all reasonable expectations at a reasonable level. Indeed, many countries manage to do this very well.
	However, it is clear to virtually all observers that we are not in that position now. We are falling behind. I look back to the halcyon days of the previous Labour Government, when, by 2010, we were putting in almost 9% of GDP, we had got rid of the waiting lists, accident and emergency waits were down, GPs could be seen on the same day and patient satisfaction was high. Now we have problems in all those areas. We have cut the share of the national cake from more than 9% to around 7%. I understand the need for austerity measures, but may I ask the Minister: what is the justification for reducing the proportion of GDP spent on health? Bringing the share of GDP up to a reasonable level is something a country with as high a GDP as ours, and more billionaires per square inch, can afford. All the problems due to these stringencies have, of course, been spelt out in reports from the King’s Fund, the Nuffield Trust and the health service managers who are heading for huge deficits this year. I fear that these are just the conditions in which research and
	innovation are squeezed out. As the scientific adviser of the Association of Medical Research Charities, I find that particularly disheartening.
	Of course, I recognise that there are more efficiency gains to be made. I want to provide one or two examples where the system under which the NHS labours is causing a terrible waste of money, and where efficiency has gone out of the window. I have a friend who is a distinguished gastroenterologist and who is desperately trying to do his best for his patients and at the same time save money for the NHS. Here, I must express my interest as a one-time gastroenterologist way back in the dark ages. My friend was trying hard to fulfil one of the major requirements of NHS England—to move much more care out into the community and reduce the cost of hospital care—so he started running out-patient consultations by telephone instead of bringing the patients up to the hospital. That saved them much time and effort, and they loved it. He also knew that the tariff paid by the CCG for each out-patient consultation was around £150, while a telephone or face-time consultation cost £29. That is a considerable saving to the NHS and a win-win situation. However, noble Lords might imagine how that was perceived in his trust. He was called in to meet a middle manager, who told him in no uncertain terms that he must stop this because the trust could not afford to lose the funding that his activities were causing, so he stopped for a while but has reintroduced the practice surreptitiously and is waiting for the trust to call.
	My friend also wanted to set up a one-stop clinic for patients needing endoscopies, seeing them in the morning, treating them the same day and giving them their results later the same day. This saved patients waiting 12 weeks for an endoscopy and three more weeks for the results—just what the NHS should be about: efficient, convenient service. But again, the incentives for the trust got in the way. Trusts lose money when patients attend only once instead of three times.
	I doubt whether this is a unique phenomenon, and it is a clear result of the disincentives we have set up in the internal market. So long as providers are desperate for funds from purchasers, we will run into this type of problem. So my question for the Minister is: is the internal market broken and counterproductive, and, especially when we are under such financial constraints, would not an integrated budgetary system be more suited to our needs? How do the Government envisage achieving their objectives of integrating community and hospital care, hitting savings targets and improving the care of patients while we have this dysfunctional internal market? The question is not whether we can afford a health service free at the point of delivery but whether we can afford one that is hidebound by disincentives in the way I have described. I look forward to his response.

Baroness Emerton: My Lords, I, too, congratulate my noble friend Lord Patel on securing this debate and on his timely contribution.
	I refer back to the 1942 Beveridge report and the six years it took for the politicians to agree the NHS Bill and launch the NHS. I have been privileged to serve
	the NHS for 60 years, during which time many reports have been published proposing changes to meet the needs of the times.
	I looked back to 1948—three years post-war—when ration books were still in use and young men were called up for national service. One thing was very apparent in 1948—the NHS would not have to deal with obesity. My thoughts wandered further and I wondered if the Minister might consider treating the national obesity problem by reintroducing rationing and national service—one way of improving the general health of the population, but I fear it would not be too popular.
	Since the inception of the NHS, much progress has been made in diagnostics and the treatment of disease, alongside progress in the fields of medicine, nursing, midwifery and professions allied to medicine. There have been changes in the management of the services, usually heralded by the dreaded word “reorganisation”. Some of these have been for better, and some for worse. The nursing and midwifery professions have had their share of changes in regulation, education, practice and management; again, some for better, and some for worse. I believe the nursing and midwifery professions have in fact weathered the changes with positive outcomes. Nurses always rise to the occasion and many might describe them as unsung heroes or heroines because they always go the extra mile, not just because of the NHS constitution or their code of conduct, as important as those are, but because they really care about the delivery of care to patients. However, the two professions are generally poorly understood, as explained in the recently published book by Davina Allen, The Invisible Work of Nurses. She writes:
	“There is a widely held view that all systems tend towards disorder and that energy is required to maintain order. Nurses are the source of this energy in healthcare. Formal organisations have a tendency to overestimate their orderliness and the degree to which their activities are governed by rational systems and processes. Yet in so far as healthcare exhibits any order, the findings of this study show, this must be understood as a nursing order”.
	It is timely for me to pursue this a little further as there is a great risk, as Ministers and the Government make decisions quickly in order to deal with the current financial issues, in looking for quick ways to solve the problems. In the current situation, the role and complexity of the work of nurses and midwives is poorly understood, especially the role of the registered nurse. There is categorical evidence that degree-level education of nurses is associated with lower mortality rates in hospitals. Suggesting that another level of registered nurses might be the answer ignores all the previous research, which demonstrated that the state-enrolled nurse was “abused” and “misused”. This was to the detriment of safe care to patients and unfair to the enrolled nurses, who were placed in impossible positions, leading to many mistakes. The opportunity to develop further the roles of the current workforce would be more appropriate, in order that new models of care could be introduced to assist in developing new pathways of patient care—integrated care, for example. The support to the registered nurse is vital, as is the work currently being undertaken by the noble Lord, Lord Willis.
	Planning the nursing and midwifery workforce in a time of national economic difficulty and ensuring the safety and delivery of high-quality care is not an easy task. But it is imperative that it is guided by a proven evidence base. If the outcome is unaffordable then difficult decisions have to be made as to the level of service that can be provided, or money found to meet the costs. These are hard decisions but it is better to be safe than sorry. Another Mid Staffordshire, Winterbourne View or Morecambe Bay cannot be afforded and it would be wrong to exploit the nursing and midwifery professions against an evidence base. The largest single workforce in the NHS cannot be expected to sacrifice its professionalism for a political expediency at a high risk to patients. The Chief Nursing Officer, who is leading this piece of work, needs the full support of the professions and the understanding of the politicians. Where would the NHS be without the seven-day service given by nurses and midwives now and in the future?

Baroness Gardner of Parkes: My Lords, I add my comments to others that it is a great thing that the noble Lord, Lord Patel, has brought forward this debate today. As a former dentist, I was the first woman to be appointed to the former Standing Dental Advisory Committee for England and Wales, and later a member of the General Dental Council. As one of the very few dentists in the House, I felt that I should make one or two remarks about dentistry.
	I was very disturbed to see the news that Manchester has a serious problem with children requiring full clearance of their deciduous teeth under general anaesthetic. The cost to the local NHS budget is a serious issue and a bed shortage has been created because these children are being hospitalised for a considerable time. I have suggested in this House that such cases could be dealt with in day treatment centres, but as a result I have received some quite abusive emails about the risks that would be created for these children in substandard clinics. Why should they be substandard? I am suggesting a day centre that really is right up to standard.
	I have just had cataract operations in a day surgery and they were splendid. The operations were done in a first-class specialist London hospital, the Western Eye Hospital in Marylebone, although I am sure that there are many such hospitals. Some of the operations are done under local anaesthetic and some under general anaesthetic. As patients we spent a day at the clinic and did not take up any beds. I met some people having their second operation whom I had seen when they had the first one, and when we compared notes we saw that we had all made good recoveries. A day centre that is fully staffed with a competent general anaesthetic specialty available would be so much better, not only in terms of saving money for the NHS, but also for children and their families. It is quite frightening for a small child to be stuck in a hospital for a night, so to do so unnecessarily and at great expense is, I think, really too much.
	I want to make one other point about Manchester. When the city gets all these new powers, I hope that it also gets a bit of sense. The real problem with Manchester in dental terms is that there is a great deal of opposition
	to the fluoridation of the water supply. I ask Questions about this subject all the time. The worst performer in the whole of the UK, according to the decayed, missing and filled teeth index, is Manchester, while Birmingham is the best. The Question I ask every so often to keep it before the House is this: what is the difference in other health patterns between Birmingham and Manchester? There is no difference. The really significant difference is to be found in people’s dental condition. Fluoridation could result not only in much better prevention, as advocated by the noble Lord, Lord Patel, it could also mean the saving of a great deal of money and easing of pain and discomfort for the children who are going through such a bad time at the moment.
	I agree with the noble Baroness, Lady Emerton, about nursing—I have always had a bit of a thing about this. State enrolled nurses were a very valuable force in this country. Speaking as a former chairman of one of the big London teaching hospitals, I know that some of our best nurses were state enrolled nurses. They were often people who could never have met the academic standards now required for the only qualification we have for full-time trained nurses. We now believe that they should all be university graduates. This means that we are devaluing the caring element of nursing, but I think that there is a place for it. Everyone wants to be called a nurse; no one wants to be known as a care assistant. We should definitely keep up a medium standard of training. Indeed, the Minister who answered a Question for Oral Answer earlier today said that he had views about this issue and that it probably would come back again. I hope that that is the case.
	I would like to have retained free dental examinations. In your Lordships’ House, I won a vote on an amendment on that which then went to the Commons, where they attached financial privilege and we were not allowed to debate it again. Had we retained free dental examinations, we would have picked up so many oral conditions so much earlier. Lots of people would have been saved horrible deaths from mouth cancer and others would have known that it was time to go. Even now, I believe that in any day centre that we have, someone should be looking quickly in your mouth and, if there is something abnormal, telling you to go in for a proper consultation. These things are just handled too casually.
	There is so much that can be done. It can be done sensibly and well, and does not have to cost a fortune. This is an excellent debate today and anything we can do to make the NHS more sustainable is very welcome.

Baroness Masham of Ilton: My Lords, I thank my noble friend and congratulate him on instigating this debate, which is necessary but of great concern. I must declare an interest, as I use the NHS and it saved my life after a traumatic injury. Sustaining the NHS is vital but it has many challenges. There are so many demands on the service, which is struggling to keep its head above the water.
	What can be done about the PFI hospitals? They are getting into serious debt, and is it not a fact that they may have to pay out more? This would be a
	disaster. Some of these hospitals are cutting services relating to patient care and closing wards to try to save money.
	There are many more demands on the service as the population grows older. Money needs to be saved so that it goes to patient care. If one looks at the lists of well-paid managers, many of those posts could be merged, saving money. Something must be done to make locum doctors and nurses’ posts cost less. It has got out of control. It is vital to have good, well-trained front-line staff, but if too many are from agencies it means that there is not continuity of care, which is so important. Perhaps hospitals could have their own staff banks. I agree that patients must take responsibility for their hospital or GP appointments but they must be able to contact the hospital or surgery. This can be difficult. Communication throughout the NHS should be improved.
	I feel that it is such an expense to the NHS when things go wrong. Patient safety should be top of the agenda. I hope that the duty of candour will help. There has been a culture of cover-ups for too long, which I hope will be changed to one of openness and honesty. An apology and correcting the mistake is often what is needed and that would help to lessen the need for litigation, which costs the NHS far too much. However, compensation should be paid when there is disability which is very expensive to live with.
	On Monday, I attended a meeting on orphan drugs and rare and ultra-rare conditions. We discussed the extreme stress that parents and loved ones have when their family member is denied a drug which can save their life or improve its quality. There should be co-operation with charities, the NHS and industry working together to find ways of funding these vital drugs. I wish that the Prime Minister would help over this matter. He is a person who understands these very heartbreaking situations of life and death. There should not be discrimination for the people who need the NHS more than anyone.
	Multidrug-resistant bacteria result in extra healthcare costs and productivity losses of at least €1.5 billion per annum. Each year, about 25,000 patients die in the EU from an infection caused by multidrug-resistant bacteria. London has been named the capital for TB in Europe. It is a serious public health and economic threat, demanding a concerted response.
	As president of the Spinal Injuries Association, I end by saying that delay in admittance to a spinal cord injury centre when there is a spinal injury with paralysis can lead to an increased risk of acquiring avoidable complications such as pressure ulcers, contractures and infections. These secondary complications not only are an additional health hazard to the patient but have been shown to result in longer lengths of stay and present a real risk to the functional outcome for the patient and an extra cost to the NHS. NHS England should be doing more to help and should communicate better with the specialist units, which do a difficult job and need a boost to their morale.

Lord Warner: My Lords, I, too, congratulate the noble Lord on securing this timely debate. As usual, his analysis was impeccable and very much to
	the point. We have just completed an election campaign in which undying love was professed by all the parties for the NHS and more money was promised—£8 billion to be precise, as the Chancellor said yesterday, for the period to 2020. Nevertheless, we have to move quickly now to tackle the rapidly deteriorating NHS finances, even with an extra £2 billion in prospect for the current financial year. We must also seriously up the tempo of service reform, because we have a linked cash and care crisis.
	On the care side, we at least have a plan—the five-year forward view—and a chief executive capable of implementing it, if he is allowed to do so. But the NHS has to be turned round very fast indeed, with much more emphasis on preventing ill health and much more care and treatment being provided in the community rather than in hospitals. Staff need to work in radically different ways, with much greater use of technology by a too-often luddite NHS. The budgets and care delivery of the NHS and social care must be integrated rapidly, both nationally and locally. Unchanging and failing providers have to be replaced much faster than we have been willing to do so far, with a willingness to use competition to do this. It is worth remembering that 60% of the public simply do not care whether their NHS services are provided by the public or the private sector.
	The key question now is whether the five-year forward view will resolve the NHS’s major productivity problem, whereby it produces the wrong services in the wrong way and in the wrong places. It needs an annual productivity gain of at least 2.3% stretching over the next decade. The best it has achieved in any recent year is 1.5%, and the average for the last Parliament was under 1%. Most of that was achieved by curbing staff pay, a policy that is to be continued for the rest of this Parliament. The acute and specialist hospitals are the worst offenders, with an annual productivity gain averaging 0.4% over the last Parliament—do not believe me, believe the Health Foundation.
	Unconditionally pumping more money into an unreformed NHS is probably the worst thing any Government could do, not least because the public have rumbled NHS inefficiency. The 2014 British Social Attitudes survey shows that over half the public thought the NHS wasted money. They have not yet rumbled the NHS’s track record on avoidable deaths that the noble Lord, Lord Patel, pointed out.
	We must always remember that the best predictor of future behaviour is past behaviour. The jury must definitely be out as to whether the NHS, even under its new leadership, is capable of delivering, or willing to deliver, the £22 billion of productivity gain by 2020 promised in the five-year forward view and now apparently being relied on by the Government.
	If the NHS fails, as I think it will, do the Government increase borrowing, cut other public services further or raise taxes? Without any of these, they will have to face up to finding new streams of revenue or reducing the NHS service offer. Those are the hard facts of economic life. Even if—it is unlikely—the Government manage to wriggle their way through to 2020 without making hard choices on the NHS, the Office for
	Budget Responsibility forecasts show that the NHS financial challenges will last very much longer than this Parliament.
	Our tax-funded, largely free at the point of clinical need NHS is rapidly approaching an existential moment. The voices of dissent and outrage will no doubt be deafening but a wise Government should begin now the process of helping the public engage in a discourse about future funding of the NHS. To do that requires a measure of cross-party consensus on some form of authoritative independent inquiry that could produce analysis and a range of options for a way forward. As the noble Lord, Lord Fowler, said, the start of a new Parliament is the right time to start this process for both Government and Opposition. Let us try to avoid weaponising the NHS—to use a phrase—and show a bit of political maturity from both Government and Opposition.

Lord Kakkar: My Lords, I, too, join in congratulating my noble friend Lord Patel on introducing this vitally important debate in such a thoughtful way. I declare my own interests as professor of surgery at University College London and chairman of University College London Partners’ academic health science system.
	The question of sustainability regarding the NHS is not merely one of how we preserve existing services in a prolonged period of further austerity, but rather how we develop a new framework that can deal with the changing environment in which healthcare will have to be delivered, with expanding need that will exist for decades to come. We have already heard in this insightful debate that the 1.9 million of our fellow citizens currently living with more than one long-term condition will increase by 2018 to some 2.9 million. The number of people living with arthritis will double by 2030, and the number of those living with diabetes, and of those living with dementia, will double by 2050. Success in healthcare through the application of technology, advancements and the application of knowledge derived from medical research have resulted in greater cancer survivorship, for example, but those who survive malignant disease are more likely to see a specialist in any given year and to avail themselves of general practice services. Wherever we look, we will see increased demand.
	Much thought has been given to the need for change and innovation among providers of healthcare services, and a consensus now indeed exists. There was recognition only recently of the need for greater flexibility to be given to healthcare providers to ensure that they can start to address these challenges. The review published by Sir David Dalton last year began to address this issue. It rightly identifies the need to ensure that clinical services are consistently delivered across the country, but in focusing on variation it potentially consolidates a cultural problem that makes it difficult for providers to show the courage to experiment and introduce into clinical practice new models of care, some of which may succeed and some of which may fail, but with those that succeed adopted more broadly across the system to improve clinical outcomes and drive efficiency.
	In the past, part of the proposed solution to improve the performance of providers was to introduce new legislation. The hope was that such legislation would improve the opportunity for providers to show greater flexibility and to be more innovative. Examples include the introduction of foundation trusts in 2004, and the ability for a multiplicity of providers to offer services afforded by the Health and Social Care Act 2012. Do Her Majesty’s Government believe that the current legislation, which offers significant opportunities for providers to show flexibility and innovate, is being fully exploited by healthcare providers in both the public and private sectors? Do they believe that further legislation is the answer to improving the ability of providers to innovate? What evidence is there that, two years after their creation, academic health science networks, which were designed to enable the introduction of innovation at pace and scale across health economies, are delivering the advances, improvements in care and efficiency improvements that were anticipated? In this regard, I remind noble Lords that I chair an academic health science network associated with University College London.
	Beyond legislation and driving a culture change regarding innovation, there has been increasing emphasis on trying to determine how our NHS sits in comparison with other healthcare systems. There appears to be some disparity in the conclusions reached. For instance, last year the Commonwealth Fund published its regular analysis of 10 healthcare systems and concluded that the NHS remains the number one healthcare system in terms of safe, effective, patient-centred care. As we have heard already in this debate, the Quality Watch report by the Nuffield Trust and the Health Foundation, which was published last week, concludes that among 14 OECD countries with similar increases in demand in their healthcare system, the NHS does not perform as well, with relatively high mortality rates at 30 days for stroke and myocardial infarction and relatively poor survival rates at five years for malignant disease. What role do Her Majesty’s Government believe that international comparisons play, and what methodology is the most effective for us to refer to in trying to analyse where our healthcare system sits in comparison with others?
	What analysis have Her Majesty’s Government made of other healthcare systems that are committed to equity of access and universal coverage—such as those in Germany and the Netherlands—but which use different models of funding that care, and what can we learn from those models? Have they addressed similar challenges in a more effective fashion? Have those models and systems of care been more effective at dealing with prevention as well with the management of patients with chronic conditions, at providing autonomy for healthcare providers, and at ensuring that innovation can be applied and adopted in the most effective and rapid fashion?
	Finally, how do Her Majesty’s Government propose to go about building the long-term consensus that all noble Lords who have contributed to this debate believe is vital if the longer-term sustainability of our healthcare system is to be secured? Do Her Majesty’s Government believe that there is need for an independent commission
	to establish cross-party consensus on this matter and to inform public debate, which is vital if we are to carry our fellow citizens with us as we address what will be one of the most challenging and important questions facing those responsible for public policy in the coming years?

Lord Mawhinney: My Lords, I, too, congratulate the noble Lord, Lord Patel. I very much appreciated his kind personal comment at the beginning of his speech.
	This debate is about the sustainability of the NHS, not its desirability. If you talk about its sustainability, hard words about the NHS are likely to follow. Those who issue hard words might conceivably be charged as not being as supportive of the NHS as they ought to be, so I want to make two personal statements before I start. First, for the majority of this year I have been in the intimate care of the NHS. I owe my life to Steven Tsui and to the doctors, nurses and technical staff who have looked after me so well over the past few months. Anyone who has been through what I have has to be an NHS fan. Secondly, for the record, apart from the years when I lived and worked in the United States, I have never had any private health insurance; I have been an NHS man all my life.
	I start by setting a context. When the NHS started, in its first year it employed 144,000 employees. On 30 September 2014 the UK employment total was 1.6 million. The first NHS budget was £437 million, which in today’s money is about £9 billion. This year, as the noble Lord, Lord Patel, reminded us, we are going to spend around £116 billion. In the first year we spent 3.5% of our GDP on it; as we have been reminded, this year we are going to spend around 9%. That trajectory is not sustainable.
	I turn to money. The recent King’s Fund report said that,
	“financial problems are now endemic among NHS providers, with even the most prestigious and well-run hospitals forecasting deficits”,
	this year. Are we relaxed about that? More than 25% of trusts are in deficit, some in deep deficit, and most of the rest of them are heading in that direction. In the seven years between 2006-07 and 2012-13, over and above the normal financial arrangements, the department slipped about £1.8 billion worth of cash to hospitals in addition, just to keep them going. There is one hospital in this country that in the last few years was in receipt of £1 million per week over and above its normal financial arrangements, just to keep going. I am told that one of the London teaching hospitals is £200 million in debt. Monitor predicts that by 2021 the NHS will be £30 billion in debt—and if there is one thing you can say about that figure, it is that it will be an underestimate when we get to 2021.
	I turn from money to service. I had the honour of being a member of the Select Committee on Public Services and Demographic Change. We said in 2013 that,
	“the current healthcare system is not delivering good enough healthcare for older people”.
	I noticed the president of the Royal College of Emergency Medicine saying recently that the treatment of patients at A&Es is “inhumane”. I noticed the Alzheimer’s
	Society saying that GPs are reluctant to diagnose patients with dementia because they feel there is nothing that the NHS can do. And it is a disgrace that if you go into hospital at weekends, you are 15% more likely to die than if you go in during the week.
	We have had a lot of nice things said about the NHS Five Year Forward View. I shall read one sentence from it:
	“The traditional divide between primary care, community services, and hospitals”,
	increases the barrier to the type of care that people need. None of that even hints at sustainability.
	The NHS is not only a sort of religion, it is a political football. If I were a Labour Member, I would be really pleased that we had started it. As a Conservative, I am really pleased that we have looked after it for more years than anyone else. Both sides have played their part in keeping this political football moving backwards and forwards, but it is time to blow the whistle—it is time to stop. I want to be the third ex-Health Minister, and there may be more yet to speak, who says that it is time for an independent review. It is time for an independent national commission to recommend how we should move from unsustainability to sustainability. Will the Minister’s department undertake to put pressure on the rest of the Government to set up a royal commission, or would it prefer that an independent commission was set up, independently generated?

Lord Crisp: My Lords, like others, I agree that the noble Lord, Lord Patel, is right about the need for a fresh look, going beyond politics and all the experts. We need to reframe the arguments and get others into the debate, and to take a long-term view.
	I agree with the many people who have spoken, starting with the noble Lord, Lord Fowler, about the importance of understanding and reviewing how the NHS is financed. However, I want to take these arguments a bit further and think about sustainability in the round. Sustainability is not just a financial issue. I shall give two examples. Barely 50% of children have met all their development milestones by the time they start school. This influences children’s future physical and mental health and their ability to learn. The second example is that social isolation and loneliness in old age have the equivalent health impact of smoking 15 cigarettes a day. Moreover, loneliness very much slows the rate of recovery. Your Lordships can see where I am going with this argument. I have deliberately chosen two issues that are not directly about healthcare yet the NHS has to pick up the pieces; in most cases it cannot have a direct impact on these issues, although others can.
	Sustainability is wider than that, too. If the NHS and social care are the formal healthcare system—and we have heard the figures for what that costs—the latest figures from carers’ associations is that if we were to monetise what carers provide, we would see that they provide about £120 billion worth of care. If you add into that what civil society, volunteers and all the NGOs and so on do, you see that there is a vast informal care system. My point in raising that is that
	what happens in the informal care system impacts on the formal care system, and vice versa. If the informal care system gets weaker, it puts more pressure on the NHS, and if the informal care system gets stronger, it takes some pressure off it. These are important points about sustainability, and any future commission needs to be thinking about these as well as how to finance the NHS.
	A lot has been said about prevention, but we also need to think about this in a different way as being a positive term, sometimes called “health promotion”. It is about the creation of a resilient, healthy population and society. The Minister knows that I have a debate—later in the autumn, I hope—on what I call “health creation”, which is precisely what we are talking about here. There are two simple points here, and I will not go any further: we need to think about sustainability in the round, and the NHS itself cannot make itself sustainable—others have to play a major role in that.
	My second point is that looking at financing is right, and clearly we need to chase improved efficiency at every level. However, we should not hope for too much from a review of a new financial model. I will give just two examples from around the world—again, I do not have time for more. Holland changed its system with great fanfare about five years ago so that it consisted of private insurers which then purchased from anybody. The net result of that, which was probably predictable, was that unit costs have gone down and volumes have gone up, and Holland, which now spends 25% more than we do, is spending more than it did. That was an experiment in changing the financial arrangements.
	I will not talk about co-payments—that is, getting people to pay as well—other than to say that all the studies show that if they are to be big enough, they will affect both the poor and the rich: they affect the behaviour of the rich, who then go elsewhere, while the poor cannot afford to pay for services. You can have small co-payments, but large ones have those impacts. My point is that we must look at how the NHS is financed—I understand and agree with that point—but we should not hope for too much from what others around the world have done.
	My third and final point is that in the short term you cannot take politics out of the NHS. To go back to Holland, the Dutch Government do not directly run hospitals, but the Dutch Health Minister gets all the questions about hospitals in his Parliament anyway. However, we can have a cross-party consensus about the longer term.
	I will quote from a Portuguese report—if noble Lords allow me, I will say it in English; indeed, your Lordships may prefer me to do so. Portugal is trying to transition from today’s hospital-centred and illness-based service system where things are done to or for a patient to a person-centred and health-based one where citizens are partners in health promotion and healthcare. It will use the latest knowledge and technology and will offer access to advice and high-quality services in homes and communities as well as clinics and specialist centres. It will provide a better service with lower infrastructure costs. That is Portugal’s aim over 25 years. It will not be difficult for us to construct that sort of
	consensus and vision about where we are trying to go, but we need to understand that that is a radical change. If we are to have a radical change and we are pointing in that direction, we need a clearer longer-term plan than the five-year plan we have, and we need the sort of transition fund that some people are arguing about.
	My final point is that I absolutely agree with the proposal of the noble Lord, Lord Patel, that there should be an independent reframing of the arguments, which will bring other people into the argument so that the same people are not having the same arguments, which has often been the case in the past. To do that, the starting point is to create that shared vision of where we are going, so at least we have something to steer towards, and we need to understand that sustainability is about these wider social impacts, not just about the efficient management of money within the NHS, important as that is.

Lord Cormack: My Lords, it is a great pleasure to take part in this debate, which was so splendidly introduced by my friend, the noble Lord, Lord Patel. We have had many conversations about this in the early morning in the Truro Room, so I was very confident that he would make a splendid speech, which he did. This is a refreshing debate because it has been marked by consensus. I single out the speeches of the noble Lord, Lord Warner, and my noble friend Lord Mawhinney, both of whom, in slightly different words, made the case for saying, “The time for using this as a political football is over”. We need to work from both sides of the House. No substantial difference of opinion has been expressed so far during this debate, and I hope that I will not depart from that.
	When I first entered another place 45 years ago I was a very humble PPS in the Department of Health and Social Security, where a very few Ministers—one in this House, three in the other place—looked after the whole of health and social security. When I reflect on that, I reflect on how far we have moved away from that tight-knit and rather efficiently run pattern. Of course, we now have a much larger population and a much larger surviving population. When I entered the other place I did not have a single constituent with artificial knees or hips, or with a transplant. I even wrote to those who attained the age of 80, which would not be possible now. We have moved on.
	As the noble Baroness, Lady Emerton, reminded us, it is well over 70 years since Beveridge, and 67 years since the NHS came into being. The sort of commission or inquiry which has been called for today is therefore desperately overdue. It is not the first time that a commission has been called for in your Lordships’ House. I made the call in earlier debates introduced by the noble Lord, Lord Turnberg, in which the noble Lord, Lord Patel, participated. We need an inquiry or a commission, and I would favour the latter. It must be an open-ended inquiry, with an open agenda. Nothing must be off-limits. My noble friend Lord Fowler made that plain in his speech. All forms of funding must be looked at. We have to have a plurality of funding if we are to have a sustainable NHS. Whether the extra
	funding comes from compulsory insurances or certain charges matters not, but it has to come—we have to have a quality service that does not lurch from crisis to crisis, from one application of sticking plaster to the next. It is crucial that we attain that.
	I have a great deal of confidence because my noble friend Lord Prior, who will answer this debate, was himself very recently a notable and innovative chairman of the Care Quality Commission. I hope that he will bring the experience he acquired in that important role to his role as a Minister in the department. He succeeds a greatly loved Minister in our noble friend Lord Howe. Let us now, freed from the constraints of coalition government, have the sort of boldness that the Chancellor expressed in the Budget speech yesterday. Let us have a commission or an inquiry that will look at every aspect of the NHS and of care, and which will in particular look at funding.
	All of us here believe in the NHS. There is not a politician of sense or sensitivity in any party who does not believe that. However, we must not be constrained by outmoded philosophies. We must look at the NHS and at the society it serves, and see what we can do to give it the quality service that will take us through this century and into the next. Today we heard the statistics; we know how many people will develop difficult conditions that need very sensitive treatment, sometimes for years. Many of the problems we talk about today were not problems when I was elected to the other place, because not only did some of the drugs and techniques not exist, but people then would have died long before they needed the attention we are now calling for.
	I hope that we will have a positive response from my noble friend on the Government Front Bench and that at the very least he will tell us that he will have serious conversations with the Secretary of State on this. However, if it comes to naught, which I hope it does not, we in your Lordships’ House should establish one of our special committees to look at these issues. I know, looking across and around the Chamber, that we have enough expertise; many of the people who could contribute to such a committee have spoken today. This problem will not go away. It must be addressed, and we must make sure that it is. A commission and inquiry is an idea whose time has come, and we must ensure that it happens.

Lord Desai: My Lords, it is a pleasure and a privilege to follow the noble Lord, who has such vast experience in both Houses.
	I thank my noble friend Lord Patel for introducing this debate. I think that I have spoken in every health debate that he has initiated. He is quite right to say that there ought to be a royal commission, but I expect that the Government will pour cold water on that. Any royal commission appointed any time soon would report around the time of the next election, and no Government want a royal commission report on their hands when they are trying to fight an election. Perhaps, as the noble Lord, Lord Cormack, said, we will continue this debate—and perhaps all the debates in your Lordships’ House on the National Health Service, collected together in one volume, might by themselves tell us a lot about how to cure the NHS.
	As a lot of people have said, there is a consensus that we all love the National Health Service. A number of individual experiences, including those of the noble Lord, Lord Mawhinney, tell us that it is extremely helpful and valuable to our lives. At the same time, in all the years that I have been in this country—more than 50—there has never been a time when people have not said that the NHS is in crisis. We can sustain the National Health Service only by believing that it is perpetually in crisis and that something has to be done about it.
	We tend to look at the NHS from the supply side, which involves asking how we can get more money and increase productivity, and how can we reorganise it. Every party reorganises the health service when in power and, when in opposition, criticises any reorganisation carried out by the Government. We have sustained a good National Health Service but, in my view—I have said this before in your Lordships’ House—so far we have not done anything on the demand side. Because we promise to deliver healthcare for free to whomever demands it, we have taken it for granted that all the adjustments have to be on the supply side, not the demand side.
	I believe that there are a number of things that we ought to be able to do, as some noble Lords have mentioned, to, as it is called, “nudge” the behaviour of the public who demand healthcare. If there is ever a health commission, it ought to examine how to bring about behavioural change, perhaps by providing incentives to people to change their behaviour. Yesterday, the Chancellor revived the idea of using vehicle excise duty for road building. I had always thought that the Treasury did not like hypothecated taxes but here we have a hypothecated tax. There is no reason why the Chancellor should not tax sugar and salt and link the tax quite explicitly to the health service—even though it would finance only a very small proportion of the costs. We are worried about obesity and diabetes but we do nothing about salt and sugar in food. However, there is absolutely no reason why we cannot do this. We ought to urge the Government to explore things that will influence behaviour.
	Another suggestion that I have made before in your Lordships’ House is that, although we do not want anyone to feel that they are being charged for using the health service, we ought to make clear to people the cost of providing it. People think that because it is free, it is costless—but it is not. We often worry about people missing GP appointments, so I propose a sort of health Oyster card for every citizen. Every time they used the National Health Service, they would have to swipe their Oyster card and a certain number of points would be deducted. The Oyster cards could be recharged. At the end of the year, people would get a bill showing how many points had been used and on which health service facilities. If people missed a GP appointment, 15 points would be deducted rather than two—things like that. Perhaps something like that could be done to make it clear to people that a free National Health Service is not a costless one. If we can somehow get people involved as patients and potential patients so that they modify their behaviour in demanding healthcare, it may solve some of the problems of the National Health Service.

Lord Ramsbotham: My Lords, I, too, congratulate my noble friend Lord Patel on obtaining this debate, yet again confirming his wisdom, his expertise and his commitment to an issue about which I know he cares deeply. As a mere NHS user, I hardly dare add my voice to those of the many experts who are contributing, my only qualification being that, for two years, I chaired the Hillingdon Hospitals NHS Foundation Trust, having my noble friend Lady Flather as one of my non-executive directors.
	Before making two points about the sustainability of the NHS, perhaps I may share the first of two wishes. I once worked for a general who banned the use of the words “significant”, “vital” and “basic” because they were merely pejorative and signified nothing. A distinguished psychiatrist said the same, in clinical terms, about the Home Office’s use of the words “dangerous” and “severe” to qualify a personality disorder. If I could ban one word from politics it would be “change”—pejorative for doing the opposite of what the other side did, under the delusion that it is a hallmark of political virility. In fact, change for change’s sake often leads to little more than unnecessary and expensive disruption, particularly when its consequence has not been fully assessed. In the public sector, evolution is invariably a better, or more appropriate, route to improvement than revolution. The debacle following the coalition Government charging ahead with change in their pre-planned Health and Social Care Bill, before examining the books and seeing what was possible or necessary, is a classic example of what I mean. Above all, it flew in the face of the priority plea of practitioners, which is for stability.
	Sustainability depends on maintaining and not squandering resources. Quite clearly, the biggest problem facing the NHS is the rising cost of meeting the physical and mental health needs of an ageing population. My first point is that affordability requires the ruthless elimination of anything unnecessary or wasteful, such as silo working when more than one ministry is involved. There are two examples from the criminal justice system. First, I hoped that prisons and probation would be represented on local health and well-being boards, resulting in improved support for offenders. Not only are they not represented on all, but fewer than 20% of clinical commissioning groups realise that they are responsible for meeting the physical and mental health needs of those undergoing supervision in the community. Secondly, expensive lack of co-operation between ministries is exemplified by the Ministry of Justice’s proposal for what it calls a “secure college”, detaining 320 children aged between 12 and 17, the vast majority of whom have mental health or emotional well-being problems, on one site in the middle of Leicestershire, while at the same time NHS England’s Children’s Mental Health and Emotional Well-Being Task Force is piloting a scheme to ensure that such children are kept in their home areas to ensure consistency of treatment. The Chancellor must be fuming.
	My second point concerns senseless waste of equipment and drugs. Almost four years ago my wife had four vertebrae fractured in a car accident and had to wear a plastic body brace for some weeks. When she asked the issuing NHS hospital what she should do with it
	when it was no longer needed, she was told that, because they did not re-use such things in case infection was passed on, she should throw it away. In the event, she was assessed by a consultant in a private hospital, who, on hearing this, asked whether he could have it because it was worth a lot of money and could be used many more times. Only last week I tried to decline a once-prescribed box of pills which I did not need, only to be told by the pharmacist that there was no point in handing it back because, once issued, it had to be destroyed. Individually these may be small items but, aggregated across the country, they add up to a considerable sum which the NHS surely ought to be able to find ways of saving. I hope that the current work of the NHS Confederation, working with other national bodies to explore how to make savings, will demonstrate to the Government the value of an NHS-led approach to this.
	One of the qualities that I most admired in the marvellous people who worked at Hillingdon was applied common sense. Sadly, common sense is often a victim of adversarial party politics. That is why my second wish, in the interests of stability and sustainability, is that in addition to the independent commission called for by my noble friend and many others, the future of the NHS should be subject to cross-party consensus.

Viscount Bridgeman: My Lords, I, too, associate with other noble Lords in thanking the noble Lord, Lord Patel, for this very timely debate.
	I have, on many occasions, talked to visitors from overseas who have used the NHS and who have told me how impressed and indeed amazed they were by the fact that the treatment had not cost them a penny. Free at the point of delivery is the bedrock principle of the NHS and admired throughout the world, and I will have more to say about that. This sits alongside the unpalatable fact that it is generally agreed that, by 2020, there will be a £30 billion deficit, in addition to all the deficits running at that time.
	I strongly favour a royal commission. Arguably, its most important effect would be to take the NHS out of politics to enable the whistle to be blown, as my noble friend Lord Mawhinney has said—though whether it can remain in that condition is a future challenge for abilities greater than mine. I suggest that its brief should address, among other things, the question of free at the point of delivery. This is not only an admirable ideal in itself but, over the past three or four generations, has come to be regarded as a fundamental birthright. In political terms, frankly, no party would dare to question it. However, with a royal commission, politically unfettered and drawing on many government departments other than health, there appears to me to be a once in a lifetime opportunity to address this issue. I suggest to your Lordships that such a commission would have the unbiased authority that would enable it to address the unthinkable of some form of selective contribution by patients for treatment—the noble Lord, Lord Crisp, has obliquely referred to this—moving towards the ultimate goal of a financially viable National Health Service.
	The other point that I hope the royal commission would address has fortunately been answered already by the noble Lord, Lord Kakkar, who made the point of the need to address the national healthcare services in other OECD countries, and the noble Lord, Lord Crisp, has given some examples.
	In 2002-03, general practices were offered a new contract—personal medical services—which offered better funding if they undertook more services. Those that took up the new contract tended to be the more entrepreneurial practices. In central London, to take one example, take-up was around 50%. The national policy has been to reduce PMS funding to that of GMS, the pre-existing contracts. I quote a doctor friend, who is one of the people concerned:
	“They say that they will return any saving from PMS reviews to the local health area. There is no guarantee that that would substantially make up for lost funding. In one area I know of practices that stand to lose over £400,000 pa, which will cripple them”.
	His own practice stands to lose over £300,000—we are talking about west London. He continues:
	“At a time when primary care is being promoted as a means of achieving substantial savings, by enhanced and new ways of working, it seems counterproductive to make swingeing cuts in often the most innovative and high quality practices”.
	I suggest to your Lordships that this is a very short-sighted measure.

Lord Reid of Cardowan: My Lords, I am speaking in the gap because I was not sure that I would be able to stay for the whole debate. I want to make a very short contribution. First, I thank the noble Lord, Lord Patel, who is, if I may say so, the right person, at the right time. He is the right person, because nobody can in any way doubt his commitment to the National Health Service, and it is the right time, because it is outside what has been probably the longest general election campaign, courtesy of the five-year Parliament. That refers to the point people have made about the National Health Service being used as a political football. I do not think that it will ever be taken out of politics, because politics is a series of moral choices about the commitment of scarce resources to infinite demands. But it can be taken out of party politics, and I think that today’s conversation begins to do that.
	Let me make my position very plain. First, like everyone else here, it goes without saying that I am committed to the National Health Service, not just ideologically but, like the noble Lord, Lord Mawhinney, for very practical reasons—it saved my life over 50 years ago. Secondly, I am sure that there are efficiencies that can be carried out in the National Health Service. Some have already been mentioned, but I merely mention the fact that, in procurement, even in non-medical areas, there are more than 40,000 people purchasing for the National Health Service and most of them do not know the price being paid for a particular commodity by the person sitting next to them—the other 40,000. In an age where we can “compare the market” for everything and of one-click purchases through Amazon, it seems to me incredible that that is the position in the National Health Service.
	Thirdly, I am not one of those who is opposed to the use of outsourced private services. I think that a diversity of suppliers, where appropriate, is a good thing—again, that is not just ideological, but because it was central to reducing the huge waiting lists, which were mentioned earlier, and waiting times. The provision of that range of services, appropriately used, can be efficacious in removing the pain of people who had to wait in pain for so long. However, I do not believe that the solution lies in an insurance-based system. Witness the fact that 10 years ago, when I was Secretary of State, we were spending 6% or 7% of GDP, going up now to 9%. In the United States, at that time, they were spending 17% or 18% of GDP on the combination of a private-based and supplemented system—it will be even more now with Obamacare—and over 20% of that went on bureaucracy. We have to get the balance right.
	Having said all that, the real issue is that the betrayal of the National Health Service does not lie in addressing the fundamental challenges; it lies in ignoring them and hoping that somehow this will go on sustainably and indefinitely, with a hugely increased demand. We all know why that is happening. There is an increased population, people are living longer, diseases and illnesses will become more chronic, and new treatments and technologies will be invented every day, all at a cost and rate that is above inflation. As I say, I believe that if we are committed to the National Health Service, our duty is to address this question in the long run, not to avoid it. That is why the noble Lord, Lord Patel, has opened a conversation today that does us and the National Health Service a service.

Baroness Walmsley: My Lords, this has been an excellent debate, so ably introduced by the noble Lord, Lord Patel. It is quite clear that the NHS is a national treasure and something that is dear to the hearts of all noble Lords. The principle that it is free at the point of need is something that all political parties continue rightly to support.
	Every one of us has cause to be grateful to the men and women from all nations who work in the NHS. We rely on their skills and knowledge, and those from abroad contribute enormously to it. That is why I start by asking the Minister whether he will work to persuade the Home Secretary that her determination to send home some foreign nurses who earn less than £35,000 per year is unjust and detrimental to the NHS and the people of this country.
	The prediction is that costs in the NHS will rise at 4% per year, and more and more health trusts are going into deficit, as we have heard. Yet voters are reluctant to pay for this from either raised taxes or cuts in other public services—hence today’s demand for a royal commission, which I support. The Government’s Five Year Forward View needs to act as a catalyst to create new models of delivering care that are better suited to modern health needs and promote more efficient use of NHS resources, contributing to a more sustainable health and social care system.
	I think of the NHS as an inflatable bucket with a hole in the bottom. It is impossible ever to fill up such
	a device with enough money. It is inflatable because the demands on it are constantly growing as we live longer and the birth rate increases. Life expectancy is going up. The number of those aged 65 to 84 will increase by more than a third in the next 20 years, and the number of those aged over 85 will double—I hope to be one of them. In addition, with ever more wonderful developments in treatment, there are more demands for them to be available for patients, but they are usually very expensive.
	The hole in the bottom of the bucket is the fact that as we learn to treat, and even eliminate, certain diseases, other preventable diseases are increasing in prevalence because of our lifestyles. Even though the Chancellor promised more money for the NHS in his Budget yesterday, there will still not be enough unless we stop up the hole in the bucket. So I think there are three watchwords: integration, innovation and prevention—the demand side referred to by the noble Lord, Lord Desai.
	On prevention, we need to get people to take more responsibility for their own health—the noble Lords, Lord Patel and Lord Crisp, called for that—and support them in doing so. We need to ensure that young people and their parents understand what a healthy lifestyle looks like and are given the means to live it, with exercise facilities, access to fresh, nutritious food, and warm, dry homes. We need to eliminate child poverty, since poverty is the major factor leading to the health inequality which decreases lifetime opportunity. We need health education to be carried out well in all schools, and public information and treatment programmes so that those adults who missed out on such education can still get the message.
	Public information programmes work well—one only has to look at the public information programme on HIV set up by the noble Lord, Lord Fowler, all those years ago to understand how well. In Australia, you cannot move without seeing information about protecting your skin from the sun and skin cancer. We could do with one of those campaigns here. Such programmes are also cost effective because many preventable diseases cost a great deal of money. Smoking costs the NHS £5.2 billion every year, but smoking prevention programmes and anti-bullying programmes in schools can return as much as £15 in savings on physical and mental health for every £1 spent. Obesity costs the NHS £4.2 billion per year and lack of exercise costs it £1.1 billion per year, according to the King’s Fund. Yet despite the fact that every £1 spent on free use of leisure centres returns £23 in reduced NHS use, quality of life and other gains, many local authorities are having to close centres rather than give free access to them. Musculoskeletal problems such as back pain and arthritis are the most common conditions that limit people’s daily lives and the largest single cause of loss of working days. They affect 8.3 million adults in England. Some, but not all, of these problems are preventable by keeping to a healthy weight and taking moderate exercise. The costs to society of poor air quality, ill health and road accidents induced by road transport exceed £40 billion per year. It has been calculated that getting one more child to walk to school can save £768. All these things can be done fairly cheaply and prevent a lot of burden on the NHS.
	Most of these preventable diseases are focused on by local authorities in their public health programmes, so I ask the Minister whether any of the extra billions of pounds for health services announced by his colleague the Chancellor yesterday will go towards prevention in the form of the vital public health programmes run by local authorities and schools. A short-term approach which reduces prevention activities, such as we have recently seen, will have a longer-term impact on healthcare services in the future, putting additional and avoidable costs on the health and social care system. Cardiovascular disease is a good case in point, where obesity and lack of exercise cause a great many of the 33,000 premature deaths from that disease every year. Here we see another problem. According to the British Heart Foundation, there is wide variation in both access to and quality of care for patients across the UK. This is of particular concern given the range of evidence-based interventions, commissioning guidance and NICE guidance that exist but which are not universally adopted across the system, resulting in suboptimal care and avoidable use of NHS resources. Significant opportunities to identify and optimally to manage patients are too often missed. Think how much could be saved if the worst lived up to the standards of the best.
	Prevention also includes vaccination and screening programmes. There is good news and bad news here. There are still parents who are reluctant to have their babies given the triple vaccine and the measles vaccine despite all the reassurances that have been given by experts, and we now find that whooping cough and measles are rising again. I was shocked to hear that the very good uptake of the human papilloma virus vaccination has recently fallen. This is a group of completely preventable diseases, so what are the Government doing to encourage all teenagers to have the vaccination?
	I heard a bit of good news at a presentation in your Lordships’ House recently. I was told about plans for a bowel scope screening programme for all 55 to 64 year-olds. The pilot schemes have shown that this reduced people’s chances of developing bowel cancer by a third and reduced the death rate from this disease by 43% because of early diagnosis. This has the potential to save the NHS £300 million each year plus great human misery. Can the Minister say when this programme will be rolled out across the country and whether it will become available also for those over 64? The breast screening programme has also saved many lives, including mine, but it ends at age 70. Given that we are all living longer, are there any plans to raise the cut-off age for routine screening?
	Prevention also requires patients to be vigilant about their own health and to go to their GP promptly if they are worried about symptoms. It then requires GPs to recognise the signs and refer people to specialists as soon as possible. Some GPs are reluctant to do this until they have commissioned more tests, but this could cause serious delay to those with disease, on the one hand, and waste a lot of needless tests, on the other, where a specialist might have recognised right away which patients needed tests and which did not. I
	refer particularly to skin cancers, where it can be difficult for the non-specialist to distinguish the benign from the dangerous.
	Early diagnosis is, of course, both a life saver and a money saver. However, it is worrying to note that the uptake of NHS health checks is currently at a disappointing 48%, well below Public Health England’s target of 66%. Some diseases are estimated to be grossly under-diagnosed. For example, four in 10 adults with hypertension, estimated at more 5 million people in England, are currently undiagnosed. This is a preventable killer disease which responds well to treatment and lifestyle changes, so we need to get on top of this under-diagnosis.
	I am pleased that the Government plan more support for British scientific and medical research. Britain has the potential to lead the world in the discovery of new personal genomic treatments which match the patient’s DNA with new drugs. As an integrated healthcare system with tens of millions of patient records, the NHS is well placed to exploit the immense potential of genomics. But these treatments have many barriers to breach before they reach the patient, and we know that the United States has a much better track record when it comes to approvals of new drugs. So I would like to hear from the Minister about the progress of the accelerated access review which was initiated in response to this situation by his noble friend Lord Freeman but about which I have not heard much recently. Can the Minister tell the House what progress has been made on that?

Lord Hunt of Kings Heath: My Lords, as we are touching on procurement, I declare an interest as president of GS1 and the Health Care Supply Association. I, too, warmly welcome the debate of the noble Lord, Lord Patel, and the excellent way that he put forward his arguments. Of course, the issue of sustainability has been asked almost every year since the NHS’s formation in 1948. Right from the start, voices said that public expectations were too high and called for explicit rationing of services. We know that almost as soon as the NHS was established, our friends in the Treasury were keen to see the introduction of charges. Indeed, in the early 1950s, charges for spectacles, dentures and then prescription charges were introduced. This was followed by the 1953 Gillebaud commission. At the time, it was thought that NHS costs were spiralling out of control and Gillebaud was asked how we could reassert control over NHS spending. In fact, he came to the conclusion that there was a popular misconception about a vast increase in costs and ended up recommending a big increase in capital expenditure.
	Through the years, we have had many other reports. Harold Wilson in opposition did not think much of royal commissions. He famously said that they took minutes and wasted years. But he was very fond of them in government and set up a royal commission on the NHS. Interestingly, its brief included the possibility of a greater reliance on other means of funding the NHS. But it was not convinced of that, and said that the claimed advantages of insurance, finance or substantial increases in charges—or co-payments, as we now call them—would outweigh the disadvantages in terms of
	equity and administrative cost. Mrs Thatcher had another go. Patrick Jenkin set up an internal review to look at the sustainability of the NHS, with potential restrictions of coverage, but it never published the results and no change took place. Now again, we are debating the sustainability of the NHS and the suggestion that a royal commission should be established.
	I do not doubt that the challenges put forward today are formidable, but I agree with my noble friend Lord Turnberg that the NHS is still sustainable. For all the problems that we face, the US Commonwealth Fund’s analysis of the NHS two years ago, on comparative terms, as the number one health system in the world at least gives us some confidence that we have something that is worth preserving—albeit one that needs developing as we try to deal with some of the issues that noble Lords have raised.
	That does not underestimate the financial gap and the productivity challenge facing the noble Lord, Lord Prior, in his new responsibilities. We talked about the £30 billion gap by 2020. We have heard the forecast from NHS England that if we achieve a 2% to 3% per annum rise in productivity, we could reduce that to £8 billion. The Government have promised that £8 billion, but I doubt that it will be seen until the 2020-21 financial year, judging by the documents published alongside the Budget yesterday. We know that historically the NHS has achieved a 0.8% productivity gain, so that would make the gap £21 billion and not £8 billion. More recently, in the last Parliament, there was a 1.5% productivity gain, but that dipped in the last two years because of the post-Francis impact of increased staffing and, because there had been cuts in training commissions, agency costs spiralled out of control.
	Then we had the report of the noble Lord, Lord Carter. My noble friend Lord Reid is quite right: clearly, in relation to procurement, there is money to be got. But even if we implemented the whole of the Carter report, which includes some brave decisions about the employment of staff midweek on wards, it would produce only £5 billion. Put all that together and clearly there is a big gap. Last year provided deficits of £822 million: this year they are projected to be £1 billion.
	Alongside that, the Government are actually increasing demand rather than discouraging it. Understandably, more people want access—but 24/7 access? The NHS Choices website is always encouraging people to use the service more and more. It was right for my noble friend Lord Desai to ask the noble Lord about the tension between this desire to give greater accessibility and the issue of demand management. We are reaching a difficult point where the two are not deliverable.
	I hope that the Minister will say how he thinks productivity will be improved, but another issue that is vitally important is the quality of management and leadership in the NHS. The challenge is daunting: the productivity gap, the move to seven-day working without the use of agency staff—let alone health and social care integration. At the same time, we know that at the moment performance is deteriorating. Clearly, we need the best possible managers and leaders. I am sure that the Minister has read the Health Service Journal report on leadership, chaired by Robert Naylor, which came
	out last month. It said that a third of trusts have either vacancies at board level for key leaders or were employing highly expensive interns. There is a 20% vacancy rate for financial directors and chief operating officers. One in six trusts has no substantive chief executive. One in 10 has retained the same CEO for more than a decade, but the median time in post for a trust CEO is a mere two and a half years. One in five CEOs has been in post for less than a year.
	Nigel Edwards of the Nuffield Trust has said that high executive turnover,
	“has a chilling effect on the willingness of chief executive officers to take bold initiatives and encourages a passive and responsive culture”.
	In other words, the fact that chief executives are in fear of losing their jobs encourages the kind of culture that will make sure that we cannot deliver the productivity challenge. I agree with my noble friend Lord Warner that there is no chance whatever that the Government will get to 2020 with a 3% to 4% productivity gain with the current culture—a blame culture with incessant interference by the regulatory bodies and supervising bodies into the work of NHS trust chief executives
	I know that the Minister has huge experience—apart from CQC, he chaired a highly successful trust in Norwich, Norfolk—and I know that he understands this. At heart, Ministers set the tone and culture. I appeal to him to start to change the culture. He will have to put much more trust in people in the field to achieve this change. Of course we have to intervene, as my noble friend Lord Warner said, when an organisation is clearly failing, but if we carry on the way we are doing at the moment we will simply not achieve what we need to achieve, and I believe that the health and social care system will fall over.
	I know why noble Lords wish to see a royal commission established—on the face of it, it is very attractive. But I sound a note of warning. My experience of the NHS is that the moment you set up a committee of inquiry, it is always used as an excuse to put off difficult decisions. In a sense, we have in the Five Year Forward View a challenging and agreed programme—agreed by almost everybody—for the way forward. If a commission were established, it would have to be clear that its remit accepted the five-year forward plan as the way to go. I fear the killing effect of a royal commission that took two years and then a Government taking another two years to make up their mind about challenging funding issues such as co-charges. We have already had the Barker commission, set up by the King’s Fund, which went into most of the issues that noble Lords raised.
	At the end of the day, I agree with my noble friend Lord Reid that the political process will always come to the fore. The sustainability of the NHS ultimately depends on political will. In the end, it is down to Governments to make sure that the NHS provides what the public want. Do the public want the NHS to be sustained? Yes, they do.

Lord Prior of Brampton: My Lords, I thank the noble Lord, Lord Patel, for introducing this
	fascinating debate, which has covered a very wide range of subjects. I hope noble Lords will forgive me if I do not address all their questions; I may not even be able to refer to all of them by name. That is not because I did not note what they were saying but because there is just not enough time to go into what they said in detail. I do have a speech here but I am putting that to one side because I do not think it does justice to the issues that were raised today. I have some notes here instead. I will come back at the end of my speech, if that is acceptable, to discuss whether or not there should be an inquiry and, if so, what kind of inquiry or investigation it should be.
	I have a reputation at the Department of Health for being a bit of an Eeyore character because we often hear about great changes that are going to happen in the NHS but they never quite materialise. Perhaps we should stand back from the NHS for a minute. Every healthcare system in the developed world is facing almost exactly the same issues of sustainability that have been posed in the debate today. Most extreme is probably the United States of America, where healthcare accounts for over 16% of GNP. I worked in America for some time in the 1970s and I saw the cost of healthcare, which was largely loaded on to employers, literally destroy large parts of the steel and car industries. We may wish to explore alternative charging systems or different funding systems, but just moving the cost away from the state—from taxation—to insurance has not actually solved very many problems.
	Ironically, perhaps, in the light of today’s debate, the NHS is probably one of the most affordable healthcare systems in the developed world. It consumes between 7% and 9% of GNP. In Germany and France, healthcare takes between 10% and 12%. We are about average across the OECD countries but among our peers we have a relatively cheap and successful healthcare system. I was talking to people from the Mayo Clinic recently and they rate the British system as the highest-value healthcare system in the world. So we should not get too depressed about the NHS. Noble Lords have referred to the Commonwealth Fund report, Mirror, Mirror on the Wall. In every category bar one the British system is first, and that is comparing it with all the other best healthcare systems in the world.
	As my noble friend Lord Mawhinney pointed out, in 1947-48 we were spending 3.5% of GNP on healthcare—£400 million in the first year—and employing a few hundred thousand people. Clearly, since then the resources going into healthcare have expanded exponentially, and will continue to grow. The demographics, the cost of new drugs and procedures, and rising consumer expectations will drive that increase. We have heard a lot today about the importance of early prevention. That is an area we ought to explore further. As the noble Lord, Lord Crisp, mentioned, that kind of assessment should go well beyond traditional health topics.
	These pressures are common to all developed systems. It matters not how you fund the system, the pressures will still be there. My noble friend Lord Fowler was not impressed by the mention of Derek Wanless. I will quote just one small part of his report. He concluded that:
	“Private funding mechanisms tend to be inequitable, regressive … have weak incentives for cost control, high administration costs and can deter appropriate use”.
	If the noble Lord does not like Wanless, I will quote him the recent OECD report, which is only months old. It says that,
	“no broad type of healthcare system performs systematically better than another in improving the population’s health status in a cost-effective manner”.
	There is at least no evidence to suggest that a tax-funded system is less effective or efficient than any other system. Indeed, tax funding allows the collective pooling of financial risk across the whole population for collective benefit. It is this pooling of risk that makes the NHS probably one of the lowest-cost systems in the world. I see that the noble Lord, Lord Lawson, has just arrived. That reminds me of his quote:
	“The National Health Service is the closest thing the English have to a religion”.
	Actually, you do not need just belief to think that the NHS is an efficient system—there is plenty of evidence as well.
	The real question is: which healthcare systems are best equipped to beat this rising level of demand over the long term? In most industries, the forces of change that have driven productivity improvement—because in the long run everything depends on productivity improvement—have been driven by globalisation, by competition, as the noble Lord, Lord Warner, mentioned, and by consumer choice. But those drivers are weak in healthcare. The previous Labour Government tried to bring in more competition and a lot more private sector involvement. They would probably have to admit that they were disappointed by the impact. Actually, the market does not work as well for healthcare as perhaps they would have wished.
	The market does not work so well in healthcare—in any country—because there is information asymmetry in the market: the patient will always be less well-informed than the professionals in the system. It is difficult to measure the quality of care. Even in a very transparent system, as we are moving to in this country, it is difficult for patients to determine which professional in which hospital is delivering the best care. It is very difficult to assess relative quality across providers when systems are so complicated. The market structure is difficult. Inherently, there will be natural monopolies, which limit choice and competition. You cannot have two or three A&E departments operating in close proximity. There are very significant barriers to both market entry and exit. Finally, of course, there is the nature of the good itself. It is very hard to rectify things—you cannot just “send it back” when you have experienced death or serious harm in a hospital. The market will always be limited in healthcare.
	How are we going to get these improvements? How are we going to drive the kind of productivity improvement we need in the health service in the absence of a market? This is the crucial question as to whether or not our system is sustainable. If we are not able to get the productivity improvements set out in the NHS Five Year Forward View, the sustainability of our system is very much in question. The answer that we are supporting in the five-year forward view is multifaceted. We want to see new models of care.
	The noble Lord, Lord Turnberg, gave an interesting example of how in his own speciality of gastroenterology the tariff structure can lead to completely the opposite result to the one that was intended when the tariff was introduced. The only answer to the question that he posed is a much more integrated structure, where capitated payments are made and there are integrated models of care. The days of the stand-alone acute hospital are gone—if they were ever there. No man is an island; no acute hospital is an island. There may be a few hospitals—perhaps in London or Cambridge—which have tertiary and teaching income and can plough their own furrow, but I would argue that the vast majority of acute hospitals must integrate much more with their local healthcare and social care systems.
	A number of noble Lords pointed out the deficits that are currently mounting up in acute trusts. It is interesting that it was a Labour Government who introduced foundation trusts. Perversely, although it was not the intention at the time, foundation trusts make it more difficult to integrate. Rightly, in many ways they are obsessed with their own profit and loss accounts and balance sheets and are unable to look more broadly across the system. We will see new models of care.
	The noble Lord, Lord Reid, a former Health Secretary, made reference to purchasing. In his review, the noble Lord, Lord Carter, looked at purchasing, workforce, patient flow through hospitals, medicines management and estates. The review has looked at the whole spectrum of where cost savings could be achieved, and has come up with a figure of approximately £5 billion. That figure is small in relation to £22 billion, but the noble Lord went on to say in that interim report that he believes there are many more savings to be had from getting better patient flow through the system. He has drawn attention in various meetings to the fact that some 20% of patients who are medically fit to be discharged are still in hospital beds. That goes back to the issue of better integration. If we can crack patient flows through the system, I am sure that the productivity benefits will be substantial.
	I am not as pessimistic as other noble Lords who think we cannot make those savings. The noble Lord, Lord Desai, talked about the demand side, which we have to address as well. Through a combination of supply-side and demand-side measures, we have a good chance of achieving the kind of savings set out in the Five Year Forward View. There is considerable consensus around that document. Although the Labour Party did not commit itself during the lead-up to the election to the extra funding required, there was certainly concern on the Liberal Democrat Benches and on our side—and I suspect on the Labour side as well. It would be a great pity if we were to ask for another review now, when we have considerable consensus around the Five Year Forward View.
	The noble Lord, Lord Patel, raised the fundamental issue of the balance between the state taking responsibility for healthcare and individuals taking responsibility. We have often been long on rights and short on individual responsibilities. Other noble Lords have mentioned alcohol, smoking, diet, exercise and personal responsibility. That issue would benefit from more
	debate. There is a social contract between the state and the citizen—a contract which often seems to be very one-sided.
	There is a strong moral argument for the NHS. In the latest opinion poll on the question whether people wish to have a tax-funded system, free at the point of use, providing comprehensive care to all citizens, about 90% of people were in favour of what we have. To some extent you can phrase the question to get the answer you want; however, it is remarkable that a state-run monopoly, after some 70 years, still has the degree of public support that the NHS has. To some extent, we tinker with the NHS at our peril. It is one of the only institutions we have that provides the same care—or service—to rich and poor, the lucky and the unlucky, to people born with a good genetic inheritance and those who are not. It is part of the glue that holds our society together, and I would not wish to be responsible for weakening those links. So, we have to be very careful in the messages that we give out as politicians.
	However, I have listened to the debate and the strength of feeling about whether we should take a longer-term view that goes way beyond this Parliament. The sustainability of the health service is an issue that extends out 20 years, probably, but it is one that every developed country faces. I would like to meet the noble Lord, Lord Patel, and maybe two or three others, to discuss this in more detail to see whether we can frame some kind of independent inquiry—I do not think that it needs to be a royal commission. We are not short of people who could look at this issue for us; there are health foundations, such as the Nuffield Trust and the King’s Fund. The issue is: what will the long-term demand for healthcare be in this country in 10 or 20 years’ time? Will we have the economic growth to fund it?
	At heart, our ability to have a world-class health system will depend on our ability to create the wealth in this country to fund it. I am personally convinced, having looked at many other funding systems around the world, that a tax-funded system is the right one. However, if demand for healthcare outstrips growth in the economy for a prolonged period, of course that premise has to be questioned.
	In conclusion, perhaps I might address issues such as whether there should be an independent inquiry with the noble Lord, Lord Patel, after today’s debate. I thank all noble Lords who have contributed to the debate for raising some very important issues.

Lord Patel: I thank the Minister for his response, and I am encouraged by his last comments. A 10% gain is still a gain—I would not have expected him to agree. By the way, I did not use the words, “royal commission”. I asked for an independent commission. I understand why political parties may not like the idea of a royal commission, but I am encouraged by what the Minister said.
	I am grateful to all noble Lords who have taken part. It has been an excellent debate and the stature of those who have spoken indicates the interest in the subject. I do not think that the matter will be left
	today, just for another debate. I have to say to the noble Lord, Lord Hunt, that I get the feeling that political parties want to keep the health service in some trouble all the time, so they can use that for the next election.

Lord Hunt of Kings Heath: My Lords, the noble Lord is far too cynical.

Lord Patel: I wonder what makes me cynical.
	Motion agreed.

Refugees and Migrants from Asia and Africa
	 — 
	Motion to Take Note

Moved by Lord Alton of Liverpool
	That this House takes note of the displacement of refugees and migrants from Asia and Africa and to the long-term and short-term measures to address their plight.

Lord Alton of Liverpool: My Lords, I thank my noble friends on the Cross Benches for choosing this Motion for debate, along with all noble Lords who will speak today, and the staff of the House of Lords Library for their excellent briefing note.
	In returning to a crisis which we briefly addressed in Grand Committee on 18 June, there are three things which I want to address: first, the scale of the challenge; secondly the circumstances which prevail in the countries from which migrants originate; and thirdly, our response.
	In 1938, after Kristallnacht, and the attempts of many Jews to flee Nazism, the remarkable Independent Member of Parliament, Eleanor Rathbone, known as the refugees’ MP, and noted for her hostility to appeasement, established the Parliamentary Committee on Refugees. Two years later, on 10 July 1940, in a six-hour debate, she intervened no fewer than 20 times to insist that Britain had a duty of care for the refugees being hunted down by the Nazis. She said that a nation had an obligation to give succour to those fleeing persecution, and in her words,
	“not only in the interests of humanity and of the refugees, but in the interests of security itself”.—[ Official Report , Commons, 10/7/40; col. 1212.]
	We might bear in mind those words as we reflect on the debate that she initiated. She said that those debates,
	“always begin with an acknowledgement of the terrible nature of the problem and expressions of sympathy with the victims. Then comes a tribute to the work of the voluntary organisations. Then some account of the small leisurely steps taken by the Government. Next, a recital of the obstacles—fear of anti-semitism, or the jealousy of the unemployed, or of encouraging other nations to offload their Jews on to us”.
	We may no longer be dealing with Jewish refugees, but there are many parallels. Perhaps her hard-headed humanitarianism should form the backdrop to our debate, which is taking place in the context of the largest movement of peoples since World War II.
	I turn to the scale of the challenge facing us. At the conclusion of 2014, the United Nations’ refugee agency, the UNHCR, reported that, worldwide, 54.9 million people were refugees, asylum seekers or internally displaced persons, with a further 59.5 million forcibly displaced. The UNHCR says that Africa has 4.6 million refugees and 10 million internally displaced people under its mandate. Darfur alone, where I visited refugee camps, has seen the loss of 300,000 lives, more than 2 million displaced, with 400,000 more IDPs added last year alone.
	In Asia, there are 9 million refugees and 15 million internally displaced people. Afghanistan generates the second largest number of refugees worldwide, while Burma is awash with refugees, including thousands of Rohingyas, cast adrift in rickety boats in the Andaman Sea. These new boat people bring to mind the Vietnamese boat people, whose camps I visited as a young MP. I also served as president of Karenaid. Last week the noble Earl confirmed that there are 110,094 Karen refugees in camps, which I visited on the Burmese border. Some have been there for decades. Will the noble Earl say whether we are talking to ASEAN about developing a strategy for that region’s refugees and what practical help we are giving to search, rescue and resettlement?
	Of course, much closer to home, destitution and desperation have arrived on our own European doorstep, with half a million more people reported to be in Libya waiting to join the exodus. Some 46% of those making these perilous crossings originate from Eritrea or Syria, where we continue to witness the worst humanitarian catastrophe of our time. Human beings are being turned into flotsam and jetsam, with some 3,500 people fished from the sea, dead, with 1,800 corpses reclaimed this year alone. And who can forget the harrowing images of the hundreds who died in April when their fishing boat capsized, or the rescue from “Ezadeen”, a livestock freighter, when 360 Syrian refugees—including 70 children—were seized from the clutches of racketeers?
	This year 137,000 migrants, including 6,413 children, 4,063 of whom were unaccompanied, have so far reached southern Europe. Will the noble Earl say—when children, inevitably the most vulnerable, are involved—how we meet our obligations under the UN Convention on the Rights of the Child? Is he aware of the call made only yesterday by Save the Children that, as a matter of urgency, the United Kingdom should take 1,500 children immediately, a request that I certainly agree with? Some of those children have been brought to safety by the gallant crew of HMS “Bulwark”; we all pay tribute to their rescuing thousands of migrants. However, its replacement, HMS “Enterprise”, has a much smaller capacity. The Government need to tell us how they expect “Enterprise” to balance rescue operations and the apprehension of smugglers, and to clarify the legal status of those who are rescued by a Royal Navy ship, as asked for on 18 June by my noble friend Lord Kerr of Kinlochard.
	Those fleeing have to raise staggering sums of money, often indebting themselves to the smugglers, leading to exploitation and slave labour. Italian sources say that smuggling is generating revenue for organised
	crime and terrorist organisations such as ISIS. Will the noble Earl tell us how many of these profiteers have been arrested or prosecuted? Italy has spent some €800 million on rescue operations and in camps such as Lampedusa. Matteo Renzi, Italy’s Prime Minister, rightly describes the EU’s collective response as “largely insufficient”. Italy and Greece are inundated with refugees, and now a land route has opened between Turkey, Macedonia and Serbia, with an estimated 60,000 people illegally entering Hungary in 2015. As recently as Tuesday, 19 died when a smuggler’s boat heading for Greece capsized.
	Last week, Hungary indefinitely suspended EU asylum rules and is considering erecting high fences along its borders, in a Europe which once rejoiced in the smashing down of walls. But is that so very different from the high-security fences being erected in Calais, where, in the course of just four hours, 350 stowaways were evicted from British-bound lorries in scenes reminiscent of bedlam? Fifteen people living in makeshift camps in Calais have died in the last 12 months. This week, we heard of a further death of someone on a cross-channel freight train. FRONTEX, the European border agency, says that it is completely overwhelmed, and with Italy also threatening to disregard the Schengen rules it is clear that no one country can deal with this crisis and that it requires careful reflection about free movement. It is a global crisis in need of global solutions.
	Those numbing statistics tell only a part of the story. What surely matters most is why people are risking their lives and what our response should be. It is abundantly clear that populations will continue to haemorrhage unless we tackle the reasons for these vast displacements at source. Four of the countries generating the most migrants and refugees are Syria, Sudan, South Sudan and Eritrea. I shall use them to illustrate my point as I argue that the House should carefully consider the connection between our foreign affairs, defence and development policies, and their interplay with mass migration, a crisis that is compounded by climate change. I know that that is something that the noble Lord, Lord Lawson, who is in his place, is particularly interested in, but if climate change is happening this situation is only going to get worse.
	Despotic governments and terrorist organisations have been the major immediate catalysts for conflict and mass migration, but aerial bombardment without a presence on the ground, a post-conflict development strategy, or a new attempt at creating peace will simply generate more refugees. Last week I met a leading figure from a humanitarian group working in Syria and Lebanon. He described the 1.5 million refugees in Lebanon as,
	“a demographic bombshell, threatening the stability of that country”.
	In the 1980s I visited Lebanon’s Palestinian refugee camps at Shatila and Sabra; leave people to fester in a refugee camp such as those and you create cannon fodder for terrorists and militias. I wonder whether the new refugees will suffer a similar fate of being in camps 30 years later. In the short term, what we are doing to ensure that bolder steps are taken under United Nations Security Council Resolutions 2165 and 2191 to deliver aid securely to Syria for longer
	periods of time, reaching more civilians in need, might help to stem that flow of refugees. I would be grateful if the Minister would tell us what we are doing about that. Ministers have rightly argued that those responsible for Syria’s atrocities should be tried in the International Criminal Court, but have we taken that proposal back to the Security Council, which initially rejected it because of the vetoes of China and Russia?
	Today is the fourth anniversary of South Sudan’s independence, but there is little to celebrate. At a briefing this morning that my noble friend Lord Sandwich and I attended we were told that conflict there has generated more than 2 million displaced people and half a million refugees, while in the north, 12 July marks five years since Sudan’s President Omar al-Bashir had genocide added to the list of crimes he is accused of having committed—the 300,000 deaths in Darfur and 2 million refugees I referred to earlier. Yet, last month, al-Bashir travelled freely to an African Union summit in South Africa. Failure to arrest him was a blow to every refugee forced to flee their home, and to the rule of law. It undermines the authority of the United Nations. What does this culture of impunity say to other despots who we now want to bring before the ICC?
	Even while al-Bashir was safely travelling home, the United Nations published the findings of its commission of inquiry into human rights in Eritrea—my third example of the need to tackle the sources of migration.
	The United Nations found that,
	“systematic, widespread and gross human rights violations have been and are being committed in Eritrea under the authority of the Government”.
	The report also says: that it is wrong to describe the drivers fuelling mass migration as purely economic, and:
	“Eritreans are fleeing severe human rights violations in their country and are in need of international protection”.
	Every month around 5,000 people leave Eritrea—more than 350,000 so far—around 10% of the entire population. The UN says that, during their journeys:
	“Thousands of Eritreans are killed at sea while attempting to reach European shores. The practice of kidnapping migrating individuals, who are released on ransom after enduring horrible torture or killed, targets Eritreans in particular”.
	Noble Lords will have seen reports that some Christian Eritreans who reached Libya have been beheaded by ISIS, which it then publicised, with all its barbarity, on YouTube.
	Those Eritrean refugees who have been forced to return have then been arrested, detained and subjected to ill treatment and torture. So refugees from Eritrea, Sudan and Syria, comprising more than half the Mediterranean migrants, represent what we need to do—tackle the problem at source. Then we would turn the tables on mass migration, ending the tsunami of people. However, not all people fleeing their countries are refugees; some are economic migrants. We will not properly address this crisis without some bigger-picture policies aimed at them, which must include the aim of helping Africa become peaceful and prosperous, and therefore more attractive as a permanent home. This is where our development policies interplay with mass migration.
	The bigger picture includes a Europe, US and Japan which make it harder for Africa to prosper by propping up murderous, corrupt dictators with our misguided aid and arms sales; dumping our subsidised agricultural surplus on their markets; and laundering money stolen by their elites. We also need to balance the work we have done in using development programmes to train women, which were admirable, when boys and men also need economically useful skills and a sense of purpose, too. They make up the lion’s share of mass migration. In countries where economics drives migration, there should be public information campaigns, highlighting the fate of too many of those who have been lured into embarking on their perilous journeys.
	That takes me to my final point: our response A thoughtful, generous, humane, international strategic response is the only way to address this phenomenal global challenge. The children’s parlour game of pass the parcel had its origins in 1888, when a lighted candle was passed along a row of people. The first recipient says, “Jack’s alive and likely to live. If he dies in your hand, you’ve a forfeit to give”. As nations now argue about who will have to pay the forfeit, and as we hold lives in our hands, we must combat xenophobia and assert humanity’s shared responsibility. Here we should be looking at ideas like that of the noble Lord, Lord Marlesford, and one which I and colleagues flagged up in a letter to the DailyTelegraph on creating safe havens where people can be properly assessed. We must look at “taking our fair share”, as Sir Peter Sutherland, the UN Special Representative, put it. Sweden has taken 40,000 vulnerable people and Germany has taken 30,000. Although I am not arguing that this country can take everybody or solve all the problems of the world, we must certainly play our part.
	As the son of an immigrant whose first language was Irish and who married a demobbed Desert Rat whose brother gave his life in a war against Nazism, I have always loathed racism and xenophobia. In cities like the one I represented in the House of Commons, Liverpool, which calls itself the whole world in one city, I am deeply aware of the extraordinary and rich contribution which many who have arrived here have made to British society. However, I am also clear that the scale of what we currently face has the capacity to undermine community cohesion and destroy good relationships between people of different racial and religious origins. This also means that there are significant security implications in failing to tackle this challenge effectively and humanely.
	I began by quoting from Eleanor Rathbone’s speech made in 1940. She concluded that it was,
	“not only in the interests of humanity and of the refugees, but in the interests of security itself”,
	to tackle these problems head-on. I beg to move.

Lord Higgins: My Lords, this debate is very much an extension of the excellent one which we had in the Moses Room on 18 June. I concluded my remarks on that occasion by saying that the matter is so important we must have an urgent debate,
	“on the Floor of the House at a very early date”.—[ Official Report , 18/6/15; col. GC 48.]
	I therefore wholeheartedly support the noble Lord, Lord Alton, and congratulate him on achieving this debate and on his excellent and very comprehensive speech.
	This country has had a good record on refugees. I pointed out in the earlier debate that I am now the sole survivor of a Cabinet committee which recommended to the Heath Government back in the 1970s that we should admit the Kenyan Asians who were refugees from Mr Amin. However, the way in which we have reacted to refugee crises has not always been the same. As I also pointed out, we behaved very badly towards refugees when World War II broke out by confiscating all their assets.
	Having said that, the issues we are discussing are set out very clearly in the article which my right honourable friend the Home Secretary wrote in the Times of 13 May, in which she put forward a number of proposals which I think we all very much support. However, they all require action. What concerns me is that remarkably little seems to have been done either on our part or in Europe, which is distracted perhaps by the Greek affair, or in the United Nations. It is very important that we should do something positive rather than simply debate the issues. I look forward to hearing my noble friend’s reply on that point.
	My right honourable friend the Home Secretary’s main theme is that we must do nothing which would encourage more refugees to take the risk involved in crossing the Mediterranean, or which would make the task of the people traffickers easier. In that context, I am somewhat concerned. Of course, it is marvellous, and no one supports more strongly than me the idea that we should maintain the basic principles of rescue at sea. However, I am concerned that we probably need to divide the issue of rescue at sea from that of entry to the European Union.
	I tabled a Written Question to the Government regarding the position of British naval vessels, and where they disembark the migrants who are taken on board. I think that the same would apply to the Belgian ship which I saw the other day with a huge number of refugees. I got the following reply:
	“Under the International Convention for the Safety of Life at Sea, the government responsible for the Search and Rescue Region in which assistance to those in distress at sea has occurred has the primary responsibility for ensuring that survivors are disembarked at the most convenient place of safety, with minimum deviation for the rescuing vessel.
	The Italian Maritime Rescue Coordination Centre (IMRCC) manages all rescues in the Central Mediterranean area of operations. At present, those rescued in the Central Mediterranean are brought to shore in Italy, in ports determined by the IMRCC”.
	However, it is clear that that is not consistent with the position the Home Secretary takes, which is that we should do nothing to encourage people to take the risks or help the traffickers. Clearly, people are more likely to take the risks if they think that the ship is not likely to make it all the way to Italy and they will be rescued on the way. Of course, they have to be rescued, but the issue then is where they are disembarked. If it is known that they will then be disembarked at a convenient port in Italy, that achieves their objective and makes it easier for traffickers to sell the proposal
	to them that they will make it safely. So I think there is a problem here, but this also links up with the whole issue of return.
	My noble friend the Home Secretary also made other proposals—for example, that the European Union should work to establish safe landing sites in Africa. I note an interesting speech by Mr Vaz in the other place recently, in which he suggested alternative sites for such a thing. But I ask my noble friend: is anything at all really being done to establish such a landing area? What is the policy on returning people who turn out not to be refugees but economic migrants? The Government’s policy seems clear but it is not clear that it is being implemented, and it is therefore very important that we establish exactly what the position is.
	Similarly, as far as the United Nations is concerned, I am not at all clear. There was originally a proposal that action should be taken to confiscate or destroy the boats of people traffickers, but that would apparently require a UN resolution. Has anything at all been done as far as that matter is concerned? It is very important to distinguish between refugees and economic migrants. The two are closely related, but the position of refugees is being jeopardised by all the problems created by economic migrants and their movement through Europe—without barriers between individual states—and the piling up of refugees at Calais. These are areas where we need to know what is being done by our own Government, the European Union and the UN. I hope my noble friend will give us a clear indication of that.

Baroness Kinnock of Holyhead: My Lords, I pay tribute to the excellent introduction from the noble Lord, Lord Alton. I also congratulate him on his tireless and determined work supporting all those who seek justice, human rights and freedom. It has been my privilege to work with him on a number of challenging issues.
	How can we live with the endless stories of the misery and suffering of people who feel that they have no choice but to risk life and limb in order to leave their countries? How can we urgently and effectively address the growing migration crises, when EU member states have absolutely no solution and have failed to agree on migrant resettlement? Every day we hear stories of so many people who risk everything, travelling huge distances in appalling conditions and taking mortal risks on land and, indeed, on sea. We are seeing terrible human suffering at Europe’s borders as thousands of people struggle to reach safety, with little or no assistance. I regret that the European Union, including the UK, continues to renege on its humanitarian duties to put in place adequate and humane policies and practices. Hundreds of thousands of people faced with seemingly hopeless situations, which they feel powerless to change, are now fleeing their countries and seeking refuge and, indeed, a better life.
	Human Rights Watch has said,
	“research shows that most of those making the crossing are taking terrible risks because they have to, not because they want to”.
	For instance, the Syrians who are seeking to travel to Europe are not after UK welfare benefits, as some
	would suggest. They are seeking to leave a county experiencing a vicious civil war, in which their children’s schools are attacked by barrel bombs and they live every day in fear of chemical weapons. Does the Minister agree that it would be best if the Home Secretary stopped referring to the “pull factor”, which suggests that these people who head for Europe are taking unimaginable risks because they are making a lifestyle choice? Surely it is more accurate to refer to “push factors”—60% of the people seeking refuge originate from Syria, Eritrea, Somalia and Afghanistan. They flee their homes because they have to and because they fear extreme violence, egregious human rights abuses, desperate humanitarian conditions and, of course, the absence of hope.
	Our call today has to be for the UK to improve its active response to these tragedies. The Government have sadly already downgraded their contribution to the search-and-rescue mission and now seem to be focused on smuggling networks rather than saving lives. Does the Minister agree that the call for the creation of safe and legal routes should be at the forefront of the UK and EU response to the crises in the Mediterranean? Surely the people who in desperation make perilous journeys across land and sea deserve that. They are taking life-threatening risks because they have to, not because they want to.
	Among those compelled to take such risks are the impoverished and persecuted Rohingya, in Rakhine State in Burma, as the noble Lord, Lord Alton, said. They are oppressed by draconian travel restrictions and the denial of education, land rights and healthcare and are widely described as the most persecuted people on earth. More than 140,000 Rohingya have been confined to squalid camps. They are the world’s largest group of stateless people and are effectively banned from citizenship because the Burmese Government have scrapped the Rohingya white identity cards, and the voting rights that go with them, in Rakhine State, where they live in a state of virtual apartheid and dire poverty. Will the UK support the view that the UN Secretary-General should now take the lead in negotiating humanitarian access to Rakhine State?
	There are also the gross violations of human rights, as the noble Lord, Lord Alton, has mentioned, which are the background to the mass exodus of desperate Eritreans, who are fleeing a totalitarian state. Some 5,000 Eritreans embark each month on their journey to escape what the UN has described as “gross human rights violations”. The truth is that the cruelty and oppression of President Isaias Afewerki and his regime is such that all rights and freedoms are being denied to those people. What is the Minister’s assessment of the claims made that, in spite of the deteriorating situation described by the UN rapporteur, the EU is now minded to engage with Eritrea on the basis that, such has been progress, engagement is now appropriate?
	Finally, the UN High Commissioner for Refugees has said:
	“European countries must shoulder their fair share in responding to the refugee crisis, at home and abroad”,
	and that:
	“To deny that responsibility is to threaten the very building blocks of the humanitarian system Europe worked so hard to build”.

Lord Maclennan of Rogart: I congratulate the noble Lord, Lord Alton, on initiating this debate and allowing the House to confront the deep tragedy facing the world. We cannot in this country deal with the 54 million migrants whom the UN High Commissioner for Refugees has spoken about. But we should be coming to terms with the European Union in dealing with those migrants from north Africa who are flooding into Europe. We ought to recognise that other countries in Europe are doing far more than we are to face this tragedy. Since the resolution of the European Union in April, following the death of 800 people, we have given some support to the saving of lives. We have initiated the work of the Navy—HMS “Bulwark” and, later, HMS “Enterprise”. It seems that we need to maintain this at the level which we started at, as the risks are very serious. A UN study indicates that this year 137,000 migrants have crossed the Mediterranean and that migrant deaths amount to almost 2,000. That is a human tragedy of gigantic proportions for which we must take responsibility.
	In particular, we must recognise that we need to help the Italians and the Greeks, who are making considerable financial and social efforts to deal with the problem. The Italians have indicated that the majority of the people arriving in Italy by sea are from Syria—42,323 out of 170,000. The second-largest group comes from Eritrea, at 34,329. The UN inquiry into Eritrea demonstrates that, contrary to the view of the Foreign and Commonwealth Office, the country’s citizens are suffering greatly from crimes against humanity. There are extrajudicial killings, torture, rape, indefinite national service and forced labour. Recently the UK Government have indicated that the Eritreans are reducing national service to 18 months but, according to the UN inquiry, there is no evidence of that at all. Forced labour is not something that we should reconcile ourselves to.
	We must also recognise that the neighbouring countries of Syria have been burdened almost beyond belief by the high numbers of refugees. One in four people now in Lebanon is a refugee from Syria—25% of the population. Some 2 million people in Turkey are refugees. We have offered 187 places to the Syrians. That is ludicrous and we really must do something about it. On 13 May, the EU Commission issued an interesting and constructive report which advocates an emergency relocation and resettlement system. Unfortunately, we have not responded positively to the decision reached by the EU Council on my birthday, 26 June, that EU leaders should agree to the relocation from Italy and Greece of 40,000 people in need of international protection. We have opted out of this. If we want to take a leadership role in global society, we should work with our partners in Europe to tackle these problems.

Baroness Cox: My Lords, I also congratulate my noble friend on initiating this timely debate and on his characteristically comprehensive and compelling opening speech. It is with a heavy heart that I report the findings from my recent visits to Burma and Sudan, where I met many hundreds of refugees and
	forcibly displaced people. I focus on these areas as they are largely inaccessible to international aid organisations and are off the radar screen of the international media.
	In Sudan, the Government continue with their aerial bombardment of civilians and ground offensives in Darfur, Blue Nile and South Kordofan, the latter states known as the Two Areas. For example, in May, the South Kordofan Blue Nile Coordination Unit reported that an estimated 180 bombs, including four cluster bombs, and about 300 shells were dropped on civilian locations in the Two Areas, killing and injuring civilians, destroying livestock, and deliberately targeting crops, markets, hospitals and schools. In Sudan, there are an estimated 3.1 million internally displaced persons: 2.5 million in Darfur and more than half a million in the Two Areas. Some 3.7 million people in Sudan face crisis and stressed levels of acute food insecurity, and that number is likely to reach 4.2 million during the July to September so-called peak lean season.
	In Burma, I was pleased to report positive developments following a visit to Chin state in February, but a subsequent visit has sadly revealed that military offensives by the Burmese army continue to cause mass displacement and great suffering in Shan and Kachin states, despite ceasefire agreements and peace negotiations. More than half a million people have fled to neighbouring countries, and more than 600,000 have been internally displaced. Furthermore, the Government are encouraging unscrupulous mega-developments, including dam-building and mining, creating displacement of local populations without adequate consultation and sometimes with no compensation, causing further large-scale displacement. For example, according to International Rivers, in one project alone, 60,000 people have been forcibly relocated by the Ta Sang-Mongtong dam on the Salween river.
	Conditions in the camps for displaced people are dire and worsening. Flooding has recently caused food shortages and the destruction of shelters in the camps for the Rohingya, many of whom, as we know, have risked and lost their lives as they flee from violent attacks on their communities and unbearable conditions in the camps, as highlighted by the noble Baroness, Lady Kinnock. On the Thai-Burma border, in camps for the Shan and Kachin IDPs, problems abound with health risks such as the rise of dengue fever and severe food shortages. For example, the daily allowance for IDPs in Kachin state has been cut to the equivalent of less than 20 US cents a day. It is not possible to live on that, and the Kachin Peace Network claims that only 17% of the basic needs of IDPs are currently being met. We have visited these camps and seen the conditions.
	In this context, the decision of the UK Government and DfID to refrain from providing any cross-border aid to civilians trapped behind closed borders in Sudan and to reduce cross-border aid to community-based organisations working across the border in Burma, other than the Thai-Burma Border Consortium, is immensely disturbing. The United Nations Office for the Coordination of Humanitarian Affairs estimates that more than 50% of IDPs in Burma are in non-government controlled areas and are therefore not receiving any aid from the Burmese Government, aid channels or international NGOs. It has always been
	the policy of my own small NGO, the Humanitarian Aid Relief Trust—HART—to work with local, community-based organisations which can reach people who are trapped in these situations and which do not withdraw in times of danger and insecurity. We visit them regularly and have seen again and again how these organisations are highly effective at delivering aid to their people in greatest need. We receive comprehensive reports and are continually impressed by their accountability. These CBOs provide food, medical and educational supplies, and they are trusted by the local people. I hope, therefore, that Her Majesty’s Government and DfID will reconsider their position on working with such community-based organisations.
	In conclusion, perhaps I may highlight three priorities that are essentially similar for both countries and ask the Minister how Her Majesty’s Government are responding or will respond to these challenges. The first is the urgent need to end the impunity with which the army and the Government in both Burma and Sudan continue to perpetrate military offensives and human rights abuses against their own civilians: in Sudan in Darfur, Blue Nile and South Kordofan; and in Burma against the Rohingya, Shan and Kachin peoples.
	The second priority is the need for the international community to promote political solutions which will bring genuine peace and justice for all civilians. While Her Majesty’s Government are supporting the political process with regard to forthcoming elections in Burma, many ethnic national peoples fear that this will not bring justice for them. In Sudan, too, it is immensely hard for the people suffering there to see any effects of Her Majesty’s Government’s interventions to bring the Sudanese Government to account for their continuing genocidal policies in Darfur and the Two Areas.
	The third priority is the need for immediate, urgent short-term interventions to relieve the suffering of these displaced civilians, especially those trapped in areas where their Governments do not allow access to humanitarian aid. I sincerely hope that the Minister will be able to offer reassurance as to how the United Kingdom will contribute to the international community’s duty to protect these civilians, and provide life-saving humanitarian aid to the refugees and displaced people currently dying at the hands of their own Governments in Sudan and Burma.

Lord Marlesford: My Lords, the House owes a debt of gratitude to the noble Lord, Lord Alton, for his continual fight on behalf of refugees. It is a particular privilege to follow the noble Baroness, Lady Cox. I believe that there is no more courageous Member of your Lordships’ House.
	Migration is a global challenge rather than an EU problem; that must mean that it is dealt with on a global basis. The forces for migration can never be removed until we live in a very different world. Conflict, chaos and persecution are the prime causes of the present migration crisis. We must continue to work on these causes, but underlying them all is the natural desire to migrate for economic benefits. That will not change. Most of the migration from sub-Saharan Africa is economic—especially, of course, from Nigeria, the largest of those countries.
	The present crisis of the Mediterranean boat people is largely reinforced by economic migrants. It is simply impossible to process people once they have arrived in Europe in a disorganised way, having either travelled illegally or been rescued because they were at peril on the sea. Once they are in Europe it is hard to sort them out, and still more difficult—and in practice often impossible—to remove them because there is nowhere that they can be sent. There are also serious security implications. With the chaos of the present system, it is hard to believe that Islamist jihadists in dangerous numbers have not been entering Europe through the Med route. Still less will the EU Commission proposals for allocating quotas, totalling 20,000, to each EU country deal with the scale of the challenge facing Italy, Greece and Malta. In the case of the UK, we have, of course, an opt-out from such a quota system.
	The criticism that we in the UK have taken only a few hundred refugees from Syria misses the point. We have provided £900 million to help more than 4 million Syrian refugees in third countries. If the whole of that sum were diverted to taking refugees into Britain, it would cover perhaps only 90,000 refugees—on the basis that the cost to the public purse for the care of each refugee in the first year is a minimum of £10,000.
	The only solution to the immediate crisis is urgently to set up holding areas outside Europe to which people can be returned for safety, sustenance, care and assessment. However, the last thing we want to do is create more overcrowded refugee camps. That is why I suggest that, through the UN, we seek to create holding areas which could in due course become new countries where there might be hope and, eventually, prosperity and even some form of democracy. I have proposed an initial holding area, probably in north Africa and perhaps somewhere on the coast of Libya. The fact that Libya is in chaos may be a reason for selecting it. The holding area would be established under a UN mandate legitimised by the Security Council. It would have to be negotiated with the Government of Libya, who would need economic and financial inducements to agree it. I envisage it becoming eventually a new world state, which I have suggested could be named Refugia. It would require a military presence to establish, protect and guard it. This, I hope, could be provided by NATO, the only world force of sufficient capability and moral integrity. Again, that would be under the authority of a Security Council resolution.
	One great natural resource that such an area would have is sunshine. I have in mind the use of solar power not just for the energy that the community would need but for desalination, so as to make the desert bloom and produce food—as Libya did a couple of thousand years ago when it was a granary for the ancient world. Indeed, it included the most important of all the Greek colonies in Cyrene and Apollonia. The Israelis and the Australians are among those who have the technological expertise and experience to make this happen.
	It is axiomatic that the necessary human resources in the form of health and education would be provided from the start. World experience as to how best to do this would be mustered by the UN agencies. In April 2013, I visited a UN school for young Arab boys aged
	eight to 12 in Bethlehem in the West Bank. It was one of the most moving experiences of my life to see their bright eyes sparkling with hope.
	An example on a smaller scale, which I have also visited, were the comprehensive facilities provided in Hong Kong for the Vietnamese boat people. More than 200,000 refugees from Vietnam came to Hong Kong in the 25 years from 1975. Two-thirds were resettled round the world and a third were eventually repatriated to Vietnam. Let us remember that Hong Kong was itself established in 1841 under the auspices of the British Foreign Secretary Lord Palmerston, in an area which he described as,
	“a barren island with hardly a house upon it”.
	In authority and power, in some ways Lord Palmerston represented the United Nations of his time.
	The cost of Refugia would be a world responsibility and a prime task of the UN mandate. The EU, including the UK, should be expected to make a substantial financial contribution, not least because Refugia would be a location to which illegal immigrants arriving in Europe could be taken. What I have suggested would not be easy. It is an aspiration, but from aspirations can come hope, and from hope happiness.

Lord Luce: My Lords, in his excellent speech the noble Lord, Lord Alton, drew attention to the fact that we face the biggest migration crisis in the world since World War II. He gave us the UNHCR figures about the 60 million people who have been forcibly removed from their homes, which is almost the same as the population of this country. Another figure that brings it home even more is that over 40,000 people a day in this world are being removed forcibly from their homes.
	However, I agree with the noble Lord, Lord Higgins, that this country’s record in receiving and welcoming refugees has been a good one. Since 2008, I think that we have received more refugees in this country than every other European country except for Sweden. That is good and I welcome the fact that, if we look back to the time when we welcomed the east African Asians here, they have made an immense contribution to this nation.
	Like the noble Lord, Lord Marlesford, I want to look a little more at longer-term issues, although I do not quite go along with some of the views that he expressed about creating a new nation. But unless we look at and tackle the roots of the problem, we cannot really deal with the question of migration in a proper way. If ever anything brings home to us the fact that this country cannot be an island unto itself, it is this kind of issue. We are wholly interdependent and this very much demonstrates the British interest in being active in the world in dealing with and helping with conflict resolution.
	The immediate challenge, for us and Europe of course, brings home the fact that if there was not a European Union, there would have to be a collaboration of European states to devise a policy for approaching this problem. To my mind, the heart of the problem is that 1.5 billion people live in fragile and conflict-affected
	countries, where dictatorships have created failed states, fragmentation of states, vacuums which are filled by warlords and extremists, sectarian divisions of one kind or another, poverty and despair. It is no wonder that this creates conditions for terrorism, extremism and, of course, migration, which is what we are considering today. We only have to look, as we have seen in the debate so far, to Syria and Iraq, the Horn of Africa, Sudan and South Sudan, Afghanistan, Burma and, as has been mentioned by so many, Libya. I remember, as a former governor of Gibraltar, witnessing the number of Africans who swam across the Straits of Gibraltar from north Africa to Spain and, when some of them drowned, imagining whether I myself would have taken that kind of risk had I lived in the conditions that they lived in.
	To my mind, it is the overall strategy that matters in the long term when it comes to tackling this problem. We have to work in a multipolar world and hence internationally and through multilateral bodies such as the European Union and NATO. We have to engage with China, which has 3,200 peacekeepers operating now. We have to engage with Russia. We have to engage much more strongly with the Commonwealth, whose heads of government will be meeting in Malta in November. I hope that they will put migration and conflict resolution at a very high level on their list of priorities.
	At the same time, this has to be buttressed by a regional approach to these problems. We cannot find solutions unless there is a regional approach. We have that in Syria and in South Sudan, and we have to build on it. We did it with Indian Ocean piracy, to considerable success. We dealt with Sierra Leone in the early part of the century on that basis, with considerable success.
	We also have to remember that most of the refugees remain in their own region. Those from Syria live in Lebanon, Turkey and Jordan; 95% of Afghan refugees live in Iran and Pakistan. It is the help that we give there that matters more than anything else. I praise the efforts of DfID in giving the support it does and the new focus its aid has on job and growth creation.
	I end with two main points for the Minister to comment on. First, it seems to me that we have to have a strategy for stabilising the situation in north Africa in co-operation with north African leaders, especially in Libya. Secondly, we have to pursue very vigorously the idea of establishing multipurpose centres for migrants in transit, as near to the source of the problem as we can conceivably get it. In north Africa, we hear that there are somewhere between 500,000 and 1 million migrants living in Libya, which has not been stabilised since Gaddafi was overthrown. We all know there is rivalry between the internationally recognised Government in Tobruk and the rival Government in Tripoli and that there are rival militias in the northern part of Libya which are destabilising the situation with the help of Daesh. Obviously, it is absolutely essential that we give strong backing to the UN negotiating efforts to get a Government of national unity. It is a British and a European interest to see that and to do our utmost to prevent the situation spilling over from Libya into Tunisia, where we saw the absolute tragedy of the death of 30 British people. Do we and the
	European Union have a strategy to work with north African leaders for stability, particularly in Libya and in north Africa as a whole?
	Lastly, I come to the point about multipurpose centres for migrants. I noticed that A European Agenda on Migration, produced in May, included a proposal for working in partnership with third countries to tackle migration upstream. There were two specific proposals: first, to support countries bearing the brunt of displaced refugees through regional development and protection programmes, starting in north Africa and in the Horn of Africa and building on what we have done in the Middle East; and, secondly, to introduce a pilot multipurpose centre, to be set up in Niger—not Libya—which will provide information, local protection, resettlement opportunities and advice to migrants. I understand there will be a summit conference between the EU and the African Union in Malta to discuss all this. I would be very grateful if the Minister could say what the Government’s policy is on each of these points.

Lord Desai: My Lords, first, I thank the noble Lord, Lord Alton, who not only has given us an opportunity to debate the issue but has done excellent work over many years on this problem. My comments follow from what the noble Lords, Lord Marlesford and Lord Luce, said. I believe that this is not just an African problem but, as the subject of the debate suggests, a problem in Asia as well. It is a global problem and it is not going to go away. It is a global problem because of climate change, state collapse, dictatorships, resource scarcity—whatever. There are a lot of these people, and I do not think it makes any difference whether we call them refugees, asylum seekers or migrants. We should not engage in cheese-paring about what they are and who we will accept. This problem not only is not going to go away but will be with us over the next decade or so. It is a consequence of globalisation. We all accept that capital can move anywhere it likes—why do we not want labour to move anywhere it likes? What is this?
	One or two things need to be said. Europe as a whole has gone anti-immigration—it is regrettable, but it has. When new Labour was in power, it had a most generous open-door policy of accepting migrants from the newer members of the European Union. In the last election, not a single party could be found which would actually say something positive about immigration. That is the situation, and we have to have a global solution. That means that the European Union, especially the members who are also permanent members of the Security Council—the UK and France—ought to move the United Nations and everybody else to seek a global solution to the refugee problem.
	I will use a 19th century example. In the last 30 years of the 19th century, one-third of the population of Europe moved to America—mainly to North America but also to South America. Some of them were facing persecution, especially those from the Polish borders and so on. There is the very famous episode of Tom Mann, the trade union leader, going to the dockside in London and saying to the incoming people on the ships, “Brothers, you are welcome here, but I wish you had not come”. That is our attitude to migrants.
	I believe that the global solution could be as follows, although it is rather Utopian. There are a number of countries in the world that are empty, for example a lot of those in central Asia such as Turkmenistan, Kazakhstan et cetera. The density of population in those places is sometimes fewer than 10 people per square kilometre, whereas ours in Europe is somewhere between 200 and 300 people. It seems to me to be a very good global solution to take people who want to leave their country for whatever reasons to countries that have room for them.
	Why should they take them? This is where we must use our resources to give incentives to the recipient countries to accept these people, train them and make them settle there. I know that it is wildly Utopian, but it is a very difficult problem to solve. However, if we could engineer over the next 10 years a transition of people from Africa, Asia or wherever they are to the relatively empty countries of Asia—I do not think that there are many other empty countries left—that could be a solution to this problem.
	The people will go on coming; they will not go away. It is quite legitimate that they should have the ambition to leave their poverty-stricken country and go somewhere better. It is not true that a Libyan or a Nigerian wants to stay in Libya or Nigeria for ever. North America would not have been settled if that were the case. So let us admit that people want and are willing to go to where they can get a better life. Our response should be that if we are not going to have them, for whatever reasons, we should find them a home where we can settle them and give resources both to them and the recipient country to make life better for everyone. That is the best I can do in my six minutes.

The Earl of Sandwich: My Lords, it is always a great tonic to follow the noble Lord, Lord Desai.
	Alongside conflict, climate change and terrorism, and because of all these things, international migration has become one of the most acute problems of our time. At times, even in this debate, it seems insoluble. First, I acknowledge the extraordinary courage of aid workers and UN staff who work against the odds to bring water, food and sanitation to registered refugees and—this is often forgotten—to many others who are unregistered or displaced around the world. The UNHCR has been given the massive task of receiving these refugees and internally displaced persons—IDPs.
	I will provide just one example from Sudan, which was mentioned by my noble friend. As he said, he and I were briefed by Oxfam only this morning on the fourth anniversary of South Sudan’s independence, for which we had such hopes. More than 4 million people there face severe food insecurity, largely as a result of the conflict that affects about 40% of this young country’s population. It has already made more than 1.5 million people homeless and caused another 500,000 to flee to neighbouring countries. The UNHCR is frequently overwhelmed, as we saw many times in South Sudan last year—and in the north—not just by the numbers but by the UN itself becoming almost a party to the conflict, concealing victims from both sides of a racial and political divide.
	Palestine is another country where the UN mandate has made it almost impossible for UNRWA workers to remain independent. It is a paradox that aid workers the world over are trained to be neutral while inevitably they take the side of the victims. In the same spirit, we can imagine the Greek islanders, in the midst of their own economic struggles, opening their doors to thousands of Syrians—sometimes as many as their own population—as well as Eritreans, Somalis and even Afghans alongside their regular tourists and visitors. Most of these people melt away into other EU countries, somehow avoiding all Greek, Italian and FRONTEX reception centres on the mainland, making their way northwards towards healthier economies and prospects of greater security.
	It seems that up in the UK we have not yet grasped the urgency and scale of the problem. A large proportion of those crossing the Mediterranean, perhaps one-third, are escaping from conflict in Syria. It has lost 3.9 million people to Turkey, Jordan and Lebanon, leaving another 12.2 million in need of humanitarian assistance. We should make a particular effort to shelter more of these refugees in Europe—I know that we are doing a lot in Turkey and other countries—because this is a crisis of exceptional proportions.
	To take one example of what we can do, what is happening to the UK’s share of the UNHCR’s resettlement scheme? The Government are already receiving up to 750 refugees from different countries under the Gateway programme. More recently, they committed to providing a safe route for some hundreds of vulnerable Syrian refugees, selected because they are elderly, disabled or in some way victimised, who are given five years’ humanitarian protection status. This seems to be an admirable scheme—yet, as was mentioned, up to March only 183 had been resettled through this route. Perhaps the Minister could give us an up-to-date number and say what will happen next.
	The Government are often criticised for their poor response. They protest that more than 4,000 refugees have been granted asylum during the whole crisis and that large sums have been given to refugees in Turkey. Yet, as the noble Lord, Lord Maclennan, said, we do not match the generosity of other EU members such as, in this particular case, Germany and Sweden, and we hide behind the Dublin convention. This dictates that refugees belong in the countries of first asylum such as Spain, Italy and Greece. Is it time for this convention to be reviewed?
	The Government have done well to help rescue thousands of migrants from the ocean. Of course, the MoD is playing its part, and at its own expense. However, the Government also need to come out with new policies on migration. The only concern expressed so far is that welfare benefits must not act as a pull factor. That may be understandable: in the first debate today, we heard that the NHS may be unsustainable. Yet, to the extent that we are a healthy economy and a wealthy country, we will always be a pull factor and we also know that our economy benefits from migration. Other EU countries, whether they are in Schengen or not, need to know that we are taking our responsibilities seriously and not dumping them behind barbed wire in Calais.
	What about these safe havens? We have heard some Utopian suggestions. Does the Prime Minister still consider that we can receive refugees for processing somewhere offshore—or what exactly is he proposing? We are still very short of ideas, let alone solutions. I am glad that the EU home affairs sub-committee intends to look at migration this year. Perhaps the Government should do some more joined-up research into these problems.
	The Minister may remember that the noble Lord, Lord Ashdown, last week made a telling point about government. He said that we used to separate domestic affairs from foreign affairs but that,
	“there are no longer any issues in Britain that are domestic and that do not have an international dimension”.—[ Official Report , 2/7/15; col. 2260.]
	Of course, there was no answer to that in the debate, but this has serious repercussions for Ministers answering these debates, and it helps to explain why our national response to migration is quite blurred.
	My noble friend mentioned dealing with the problem at source, but how can a Foreign Office Minister be expected to deal with issues of international development, defence and immigration that belong to other departments? Do civil servants now groan under the weight of more joined-up cross-departmental meetings? These are the added pressures of foreign policy and accountability, and to help meet them I hope that Ministers will support the proposal for an international affairs committee of this House, which is long overdue.

Lord Taverne: My Lords, in this wide-ranging debate—most eloquently introduced by the noble Lord, Lord Alton, who is a great champion of human rights—I will concentrate on a special category of young student refugees in England who are denied the chance of further education. Polls show that some 60% of the public accept that international students hugely benefit Britain. Industry needs their skills, they bring in billions to the Treasury and they enrich the quality and income of our universities.
	However, there is a relatively small group of young student refugees in England who face despair and injustice. They are those who came to Britain as unaccompanied child refugees, who are denied a chance to go to university even if they do well at school. When unaccompanied child refugees arrive in Britain, they are looked after by local authorities, which support their education and maintenance until they are about to become adults. When they are seventeen and a half, they are asked to reapply for asylum if they were not granted asylum when they first arrived. How can 17 year-olds, who came here without parents at a very young age, prove that they were fugitives from persecution? We rightly protect these young people when they arrive, but wrongly and unreasonably ask them to prove their right to stay years later.
	If they are refused asylum, they are in limbo. If they are not granted asylum but granted a lower level of protection—discretionary leave to remain—and if they are bright and win a place at university, they are, since 2011, classified as international students who have to pay huge tuition fees which they cannot possibly
	afford. They also have to pay for their own maintenance. Before the law was changed in 2011, they were treated as home students, who pay lower tuition fees and have access to loans and possibly bursaries. Indeed, some universities waive tuition fees altogether for poor home students. The change in the law in 2011 means that bright youngsters who win a place at university find that they cannot take it up and are denied the chance to join their friends. The
	Guardian
	recently highlighted one heart-breaking case, of which many can be cited. What makes the new rules even more unjust and, indeed, absurd is that in Wales the law did not change, while in Scotland a select number of these students pay no fees at all and have access to the same sort of support as their peers.
	I recently introduced a Private Member’s Bill to reclassify students with discretionary leave to remain as home students. It is a short Bill with a very simple objective. If passed, the cost to the Treasury will be virtually nothing because the numbers involved are hundreds per year rather than thousands. Britain will gain because university graduates will provide the skills we desperately need. Talented young people who have gone through a terrible experience on the way here will no longer be denied a fundamental right: the chance to develop their talents through education. In the ballot for Private Members’ Bills, my Bill to rectify this injustice came 43rd out of 44. It has no chance of success without government support. Will the Minister press the Government seriously to consider supporting my Bill? The case for it on the grounds of national interest as well as justice is unanswerable. The cost is nugatory. How can it be justified that only student refugees in England suffer from this injustice? Surely the Government cannot refuse to take this simple step to right this wrong.

Lord Harries of Pentregarth: My Lords, the potential number of refugees and the practical challenges of dealing with this issue are so huge and daunting that it is all the more important to be clear about the fundamental principles at stake. The principles may be very difficult to implement, but let us at least be clear what they are and remain true to them.
	First, as the noble Lord, Lord Alton, so eloquently argued, the only long-term solution to this problem is to tackle it at its roots. This means the creation of stable Governments and economic prosperity in the countries from which people are fleeing. It is easy to despair about achieving this, but we must continue to do what we can, in co-operation with other Governments, to resolve issues of civil strife, as in South Sudan; to bring about Governments who respect human rights, for example in Eritrea; and, of course, to end the killings in Iraq and Syria.
	Secondly, there is a clear practical imperative to do all we can to hunt down the traffickers. We can do this only with the active co-operation of the Governments of the countries in which they are operating. In a country such as Libya, where government has virtually broken down, this is obviously very difficult. Huge sums of money are being made by traffickers. It is vital that we halt an operation that puts so many lives at risk. I am sure the whole House will be very anxious to
	learn from the Minister what success the Government are having in this regard and whether they are satisfied with the co-operation they are getting from the relevant Governments, including the split power structure in Libya.
	Thirdly, there is a clear obligation to help rescue those whose lives are immediately at risk. The importance of the long-term goal—stability in the countries from which people flee—and the intermediate one of halting the traffickers, must not be allowed to obscure what has to be done now. Yesterday, the Minister stressed that we must tackle the root cause, not just the symptoms, but they are not mutually exclusive. If you are in pain you do indeed want to find the reason for it and address its cause, but meanwhile you take pain killers.
	As we know, 3,500 people died crossing the Mediterranean in 2014, and the number this year could reach 2,000. When people’s lives are immediately at stake, as they are for those crammed into unseaworthy vessels, the moral imperative is to rescue them. We would ask this for ourselves if we were in that situation, and they are asking it of us. We now know that HMS “Bulwark”, which was capable of rescuing 1,000 people, has been replaced by HMS “Enterprise”, a survey ship only one-fifth the size. Furthermore, the task of HMS “Enterprise” will be to gather intelligence on migrant flows to prevent the smugglers’ vessels leaving North Africa in the first place. In addition, two Border Force cutters will continue to take part in EU search and rescue operations. Is the Minister satisfied that the search and rescue operation is large enough, given that HMS “Bulwark” alone saved some 4,000 lives? Of course, as the Government stress, we must break the link between getting a boat, and life in Europe, but this cannot be at the expense of letting people whom we could save drown.
	Clearly linked with the imperative to save these people—a good number of them children—from drowning is the need to treat them, once rescued, with humanity. The burden of this irregular immigration is being borne by Italy and Greece. Italy is coping with 56,000 people and Greece with 48,000. The cost to Italy is £800 million a year, but the EU is supplying only £60 million. Sharing responsibilities and burdens is fundamental to not only the whole principle of membership of the European Union but a successful policy on this issue. Does the Minister not believe there is a case for more shared support for Italy and Greece from the European Union?
	Fourthly, we have a clear obligation, which as a country we accept, to offer asylum to those who are genuinely fleeing persecution and whose lives are in danger in their country of origin. It is not always easy to distinguish such asylum seekers from economic migrants, who will often, in their desperation, tell whatever story they can in order to find something better than the endemic poverty and insecurity they may have known at home. Clearly, there is a difference of opinion between the Minister, given what he said yesterday, and the view of many others such as Amnesty International, who believe that the majority of those fleeing are not in fact just economic migrants but people fleeing from countries such as Syria and Eritrea where their lives are in danger. As the noble Baroness,
	Lady Kinnock, put it, there is a push factor, not just a pull factor. Even given this disagreement, there is a clear imperative to have a fair legal process in place that is able to assess the claims of those who seek asylum. Is the Minister satisfied that that is the case, and what percentage of those rescued from the Mediterranean have in fact sought and been granted asylum? The Minister is reported as saying that Britain is making the biggest contribution to the joint European asylum processing effort in the front-line states, with more than 1,000 days being contributed by British staff. That is not in fact very much, in terms of people deployed.
	Finally, we can do this only with others, as the noble Lord, Lord Maclennan, stressed in relation to Europe and the noble Lord, Lord Luce, said in relation to regional and international arrangements. The European Commission communication of 13 May, A European Agenda on Migration, sets out what this means in practice. The Government are indeed working closely with EU partners on some aspects of this agenda, but are we bearing our fair share of the burden? We have so far refused to take our share of the 40,000 refugees who are being relocated across Europe. I believe we can and should take more.

Lord Selsdon: My Lords, as so often, I am extremely grateful to the noble Lord, Lord Alton, for raising, in his delicate and charming way, an issue that is perhaps far greater than many of us could understand.
	I start on these issues with the advice that I was always given: before trying to determine the future, go back and have a look at the past. That is what I think I intend to do. I went to the Library, for which I have always had great respect—not only when I was on the Information Committee. You get to know the people there who have a particular interest in history, and before you know it they overwhelm you. I was overwhelmed with something like 120 sheets of A3 containing the history of the world, and I asked if I could please have a simpler brief. Now, for the first time in my life, I have an A5 brief in the form of maps.
	I begin with the partition of Africa in 1914. In order to determine the future you have to understand the past, and is it wrong sometimes to repeat the past. Your Lordships will know that, in 1914 at the time of the partition of Africa, many countries played an important part, and why should they not yet again be brought together? They were the French, the British, the Germans, the Italians, the Belgians, the Spanish and Portuguese. On this little chart we have a map of everything. One of the main objectives of this colonisation, or development, was food and raw materials. With it came the technology from the United Kingdom that led to the production of cotton and to getting things out of mines, and it was a pretty exciting exercise.
	The same was true in India, which we have forgotten. In one of my jobs I was one of the economic advisers doing a study for the Government of India on its future trade. I am afraid that I did not really know my way around India. We looked at manganese, iron ore and all sorts of things, including cotton—which seemed to have gone but now comes up again—and those
	things that you made sacks out of. Sacks, of course, have gone. India, surprisingly enough, turned itself around in a relatively short time to become a major economy in the world, not simply relying upon simple raw materials. The Indian chart shows the growth of British power in India, and shows exactly when everything happened.
	We then take my third chart, showing south-east Asia, which again is a major boom area. The question is what we as a nation that understands these countries can do. In order to understand and plan for the future, as I say, we must determine the past, so it is worth looking at what was produced in those territories in those golden years. I turn therefore to one of my favourite topics: Sudan. An old friend of mine, Sir Douglas Dodds-Parker, unwittingly bullied me into taking him to Sudan, only to find that I got fascinated by it. I had forgotten about the Gezira scheme, which grew the best long staple cotton in the world, which could still be redeveloped because the water and land are still there, as are the children of families who knew how it worked.
	I had also forgotten about the vast quantities of grain that could be produced there. We created a project called Storex Sudan. We got the Chinese involved—I was going to say that we got into bed with them—because they had suddenly decided that they wanted to do development projects in Africa. The Chinese agreed that they would build a road to the port, bring in ships and unload them. If you have ever watched Chinese unloading things, it is fascinating: they put everything on their head, walk off the ship and unload quicker than one could do it with derricks and everything else. The thought was that in Sudan all we needed was an off-take agreement for the grain—the dura—and one for the cotton, and the same families would be back again in production. In Africa we have the same scenario in countries where this is the norm. If we as a country could just put on a piece of paper, “I promise to buy and pay the bearer on demand the sum of so much per tonne”, it is amazing how very quickly orders would come about.
	My thoughts in this debate are that it is an economic debate. We must of course look at the north coast of Africa. Let us think again. Why is everyone leaving when they have potential for development in their own country? Why are they taking a risk at sea when very few of them can swim? Who are these pirates who kidnap people onshore with offers of whatever it is, and why can they not be arrested? After all, this is effectively almost the theft of human souls. I feel very strongly about this and would like to see the United Kingdom play a lead here. We do not want people leaving their own country; we want them encouraged to stay there. We can cure all the problems of diseases and we can train people well. Assisting in effectively exporting modern-day slavery is something that I do not wish to be associated with.

Lord Griffiths of Burry Port: My Lords, I want to add my own words to others who have expressed gratitude to the noble Lord, Lord Alton, for bringing this important matter to our attention.
	As usual when I intervene in debates in your Lordships’ House, it is from a rather more flesh-and-blood gritty level that I speak. I remember how many years I spent on the north coast of Haiti, for example, working with communities that I am afraid, unlike the view of the previous speaker, had no alternative resources with which to make another life. They had absolutely nothing, and the despair that I faced in hearing them argue their need to take a boat that would cross the sea to Florida was something that I shall never forget. How many families have I supported after the breadwinner has left? How many families have I seen emaciated by hunger when there was nothing they could turn to in order to alleviate that hunger?
	I have come to understand economic migration in terms other than the denigratory way in which it is referred to as an alternative to the seeking of asylum and therefore a less important objective.
	People who are hungry are hungry; people who are destitute are destitute; people who are forced to leave their families need all the attention they can get, and their cry should be heard. They should not be categorised, stereotyped, put in a neat box and written out of the equation. We have a world full of people who migrate for those reasons, and in the present emanation of this phenomenon, we have to add to that not just the breadwinner migrating but his wife and children too. This issue will not go away; we have to find a way to face it and deal with it. The dams will burst and the crowds will come, and when it happens, we who have watched it for so long must not cry wolf or say that we had not seen it or heard of it. It will come through the softer underbelly of the eastern sides of Europe as it did when the Goths, Ostrogoths, Huns and Vandals—we are all capable of looking back into history—crashed into the Roman Empire and overthrew mighty Rome itself.
	A very interesting, constructive thing is being done by a community with which I have contact. I am a patron of the Waldensian community living in Britain. “Patron” is the kind interpretation of the Italian word—“godfather” would be another. They have had 500 years of persecution. Jean Valdès was in Lyon until he and his followers were forced into Switzerland, across the Alps and into the northern part of Italy, and were eventually allowed to live above a certain level above sea level—and there only—in the mountains. They were only given some kind of official status in 1848, in an Italy just about to be born.
	These Waldensians have currently been offered money by the Italian Government to use for their own purposes—which comes from a church tax. The one body of people you could not imagine accepting a church tax would be the Waldensians, for it was the state that persecuted them over the centuries. However, they have decided to do something different with that church tax that will account for the whole of the money they get in that way. They call that project “Mediterranean Hope”; I wish I had time to spell out a few of its details. It has four different planks. The first is an observatory, as they call it, in Lampedusa, because they are very concerned that the narrative that comes out of Lampedusa is favoured by one bias or
	another, while a narrative that is people-centred, needs-centred and humanitarian needs to be posited as an alternative to the narratives that come via our news media. Therefore in the first instance they seek a good narrative.
	Secondly, they have set up a cultural centre on the island of Sicily where they take the women and children from those who have arrived in the way they have—those are vulnerable people, who are identified by the authorities and sent to them. There, with fun, friendship, games and food they are given a chance to integrate in the new community to which they have come and to rediscover themselves on foreign soil. An office has been set up in Rome; incidentally, this has been done by the Waldensians and Methodists, all the Protestant churches in Italy, the Roman Catholics—especially the community of Sant’Egidio—and other bodies from across Europe. In Rome they seek to help people to relocate. Only 20% of those who arrive at Lampedusa want to come to Italy, so Rome is the best place to process the stories, needs and background information and to get access to Italian Government offices, and their office there is in close contact with Sicily. Therefore the relocation desk is there. They have established humanitarian corridors in Morocco, on the other side of the Mediterranean, trying to identify people who may have a legitimate reason for going and help them to come safely to the place where they seek asylum. As I say, there are many more details.
	Mention has been made again and again of going back upstream, as a diplomat would put it. I remember going to Eritrea in 1993 as a representative of Christian Aid—I was on the board at the time. Christian Aid had helped the Eritrean People’s Liberation Front with material help—over the border from Sudan, as it happens, as well as from Kenya—during the time when the armed struggle against the Ethiopians was under way. I went to represent that fine body, which had done some rather shady things to get that food in. However, I found myself on the VIP invitation list. I am delighted to see my noble friend Lord Kinnock here; I was between him and President Gorbachev, because that was where my name fell alphabetically. I was therefore able to oversee the plebiscite that took place in April 1993, which happened in Keren, the second city of Eritrea. A new nation came to birth after all those years of struggle; it had been the football of the international community, kicked from one place to another, before this position had been found for it. Now that same Eritrea, which fought for freedom, decency and dignity for its people, is in gross violation of its responsibilities, and 25% of people who come to Lampedusa are from there. There must be something the international community, which has messed around with Eritrea for too long, can do with that self-contained country to produce better results. The international community could be doing better things; the problems could be alleviated; practical outcomes are possible.

The Earl of Listowel: My Lords, I join in the thanks expressed by your Lordships to my noble friend Lord Alton of Liverpool for securing this extremely important debate. In his opening comments he referred
	to Eleanor Rathbone, and I hope that he will forgive me a moment of family pride. My father was vice-chair, with Eleanor Rathbone MP, of the National Joint Committee for Spanish Relief. He is always a hard act to follow, I am afraid.
	Some of your Lordships will have seen the obituary on 1 July of Sir Nicholas Winton—he may have been mentioned earlier in the debate. This good man saved the lives of 669 children from Prague. Shortly before the Second World War, he had been due to go on a skiing holiday but he decided that he needed to go to Prague. He arranged eight trains to take these children to safety and he arranged for families in this country to take them in. He always deeply regretted that the last train did not leave and that 250 children were left behind. His family did not learn of this until he was in his 80s, and he died at the age of 106.
	I thank the previous Government for their wisdom and humanity in having chosen to enshrine in law a 0.7% commitment to international development aid. Clearly, many of those involved in the migration that we are talking about are economic migrants but, equally, many of them are in flight from the developing world. It is obviously right to seek to support fragile nations so that they do not fall into conflict and so that we avoid the sorts of troubles that we face today, so I salute the Government for making that commitment. I hope that if any young people read this speech, they will also feel pride in their nation for taking a world leadership role by supporting mothers with midwives, by supporting the education of girls and by protecting children from malaria in the developing world. I hope they will feel proud that this nation is leading the world in this area.
	I should like to make one request to the Minister following what many of your Lordships have said. Will he think very seriously about committing to provide space for 1,500 unaccompanied asylum-seeking children in this country? I shall come back to that towards the end of my remarks.
	I should like to make one other observation. My father lived through two world wars. In the Second World War, my mother—whom I was speaking to at the weekend—returned to Croydon at the age of four or five. She had been evacuated but returned during the main part of the Blitz. A factory near the bottom of her garden was bombed and of course that was quite a horrific experience for her. It is quite remarkable that we have had peace in Europe since that time. My understanding is that to a large degree that is due to the solidarity of the European Union. Members of the EU are committed to each other and have built strong trade partnerships, and that has helped to give us this long period of peace. Therefore, I agree with the noble Lord, Lord Luce, and the noble and right reverend Lord, Lord Harries, that it is in our strong self-interest as a nation to be an active and committed member of the European Union and to show solidarity with our allies in Europe: we are stronger together than we are disunited. One might say that Adolf Hitler did not die. There is always a new Hitler, and we are always stronger when we stand together against such people.
	I want to speak a little about my experience. I visited Angola with UNICEF during the civil war and saw the terrible suffering of the people there. I visited a feeding station and saw the undernourished children being fed. I visited an internally displaced people’s camp, which had been terribly neglected by the Government, and saw a young child with an open wound, which was a distressing situation to observe. Young people were being forced to act as child soldiers. We need to avoid civil conflict, which leads to these migration flows.
	I was a mature student and attended a further education college. One of my fellow students was a young man from Eritrea called Izak. He arrived here at a young age with his sister. He went on from the FE college to University College, London, and qualified as a civil engineer. It was difficult for him to live without his parents but he loved to play football, to dance and to work hard, and he was extremely successful. I valued my friendship with him. When I heard from my noble friend about the experience of many Eritreans and that some were being executed, I felt deeply saddened. These are not just statistics; they are real people.
	I see that my time is up, so I shall simply repeat my request that we show solidarity with Italy and Greece, and seek to take at least 1,500 children and give them succour in this nation.

Lord Judd: My Lords, I agree with the noble Lord about the need for solidarity with the people of Greece.
	I thank the noble Lord, Lord Alton, as others have, for having given us the opportunity for this important debate. But the awful truth is that the scale of the problem with which we are dealing will be dwarfed by what lies ahead. The consequences of climate change, the movement of peoples, and unresolved conflicts and tensions are not going to abate, and we are going to see an acceleration in the issues that face us. But there is one other issue that we have to face, particularly in this House. If we are intent on a world based on the market and the free movement of capital and goods, how on earth will we stem the inevitable movement of people that flows from that? People will go to where the centres of economic activity are strongest. This is inevitable, and we are just burying our head in the sand if we pretend otherwise.
	That brings home to us that we have a global responsibility that is second to none in helping to build and strengthen the economies of the people of the world as a whole, and in ensuring that we are not consuming the wealth and raw resources of the world in a completely selfish way that accentuates the awful reality of life for the majority of people in the world.
	We must, as has been mentioned in the debate, show a sense of respect for what others are doing. I like to raise my glass at meals to the people of Italy. They have demonstrated that they are the soul of Europe at its best. That gives us something to ponder here in the United Kingdom. We also have to remember the fortitude and generosity of the people of Lebanon, Jordan and Turkey, who, with their own comparative economic disadvantage, are opening their arms to
	welcome those fleeing conflict in Syria and elsewhere. Of course, they have been doing this—but for how long will they do this? There are already indications, certainly in Lebanon and Jordan, that people are beginning to say, “Look at our own plight. How can we go on carrying this burden?”. And that spells still more trouble ahead.
	I very much welcome and was cheered by—not, I may say, for the first time in my life—the thoughts of my noble friend Lady Kinnock. For me, she brought alive the terrible human reality of what we are talking about. We get awfully insulated in this Chamber. Here we are in this fine, beautiful building talking about these problems, but as we talk, people are drowning; as we talk, people are gasping for breath; as we talk, people are uttering their last breath, dying of starvation and in pain; as we talk, the torture and brutality that force people to move and leave is taking place. We need to keep in our mind that vivid picture of what the reality is, because in this Chamber we can become very abstract in our discussions.
	We should also in this context put on record our appreciation of those who work so hard and consistently on our behalf in the United Nations High Commission for Refugees, UNRWA, UNICEF, the Red Cross and all the other international institutions. We should take very seriously the thoughts and experience of our own voluntary agencies, which represent so often, together with their supporters and followers, the Britain to which I am sure many of us want to belong—the Britain with real heart and concern, the Britain that feels it belongs in the world, the Britain that recognises that it cannot escape from the world and the Britain which is therefore determined not just to talk about the problems with which we are confronted but to commit itself to finding the common solutions which are necessary if we are to begin to challenge such situations.
	I have one absolute conviction which I think has become an obsession; we are utterly interdependent with the world and our leadership, of whatever political persuasion—I hope that those who are offering themselves for leadership in my own party are taking this seriously—will in future be judged by how they enabled this country to join the world, to belong to the world and to play its part together with others in finding the solutions that are necessary for humanity, because, believe you me, there is no way in which in the long term the well-being of the British people can be secured without fulfilling that partnership in international community.

Baroness Hamwee: My Lords, I often feel that I would like to leave the last word with the noble Lord, Lord Judd, but I will start by thanking the noble Lord, Lord Alton. The footage of people struggling out of the sea appals us, but, if you see it when you are in Eritrea, it looks like success at reaching Europe.
	As noble Lords have said, this is a multifaceted issue, and multimillions of people are caught up in different situations, each one of whom is an individual. I fear that casting the debate only in terms of numbers, as some do—although not today—tends to validate xenophobia. I recognise the amount of money that the
	UK has given—to which the noble Lord, Lord Marlesford, referred—in response to the current situation. However, that has meant that people are sent to the camps which are supported, which in themselves are both dangerous for the individuals—this House has set up a committee to look at sexual violence in conflict, and part of that conflict is the experience in those camps—and, in the case of the Middle East, dangerous for the stability of the host countries and the region as a whole.
	Reference has been made to the Minister’s remarks yesterday about this being an issue primarily of economic migration. I share the views expressed in the responses of the noble Baroness, Lady Kinnock, and the noble and right reverend Lord, Lord Harries, and we know that a number of agencies have challenged those remarks with their figures. In my view, the demarcation line between economic migrancy and being a refugee is really not that clear—I will try to remember to keep the speech of the noble Lord, Lord Griffiths, to refer to for the future. People in that situation must face huge desperation and often display huge bravery. Of course, what they want are safe, legal routes, because without them, lives are put further at risk. Who among their families left behind knows the outcome? My noble friend Lady Manzoor asked me yesterday whether there is a central DNA database of those who are drowned and whose bodies are recovered, so that there might at some point be the possibility of their families discovering their fate. Stories of reliance on smugglers—criminals—and the abuse and exploitation suffered at stage after stage of the journey are legion.
	I read the title of this debate as extending to the plight—to use the term chosen by the noble Lord—of those who do reach the UK. In this country, they are faced perhaps with indefinite immigration detention, which in itself is harmful. It is a little part of what the noble Lord called the big picture. There are very rigid rules about family reunion. A father might reach this country and perhaps be able to bring over his dependent children and partner. However, an 18 year-old child might have to be left behind and become reliant on smugglers. Sibling relationships do not count. British citizens find it almost impossible to bring to the UK family members who are in danger.
	We are familiar with the sometimes very long waits for decisions about asylum status. We know how keen many asylum seekers are to work and the importance of work for both their own self-respect and their integration. Migrant Voice recently published a list of “Alice in Blunderland” policies and experiences. It gave as one example:
	“Because of the experiences that led asylum-seekers to flee, they can be afraid of officials”—
	and then they come here and are faced with security staff of whom they are afraid. Another example is that:
	“LGBT asylum-seekers may be asked to provide sexually explicit photographs or videos … to ‘prove’ their homosexuality”.
	Noble Lords will be able to cite comparable examples of such policies.
	A couple of weeks ago I met a doctor from Syria. I do not want to say much about it because of the danger to his family. However, people arriving here bring skills that we should be using. That fits in very
	much with the comments of my noble friend Lord Taverne. There is great concern, which I share, about asylum support rates, both as they are now and as they may be if the regulations which had to be withdrawn at the end of the last Parliament are reintroduced.
	I have been sent some articles written by journalism students who have interviewed refugees and I thought that I would share a few extracts with your Lordships. The first extract is as follows:
	“When I arrived in Kent I didn’t speak English. [I was given] a piece of paper with writing in so many different languages. I found my language on there and pointed to it, and that’s how they knew that I was from Afghanistan … I was amazed when I saw so many languages. It made me realise there were other people like me. And I thought that this must be such a good country, if it is helping all these different people”.
	Another interviewee talked about:
	“Trauma, the vulnerability that comes from being [a child] separated from their parents, and the expectation of making money to send back home”.
	That has,
	“an impact on a child’s ability to focus, concentrate and think about their long-term plans for the future”.
	In stressful cases, said one worker,
	“children wonder what the point of committing to an education is in a country that they don’t know if they’ll be able to stay in”.
	One young man said:
	“I am lost. I have nowhere to go. I can’t go forward, and I can’t go back I am worse than an animal in a cage”.
	When depression overtakes him he self-harms using a knife. He has carved the initials AFG into his arm as if to remind himself of a self-identity that is otherwise rapidly disappearing.
	As I have mentioned Afghanistan, I should also mention the local staff in Afghanistan—the interpreters and other people—who worked with our forces. They are regarded by the Taliban as traitors. By November last year, however, only 31 had been given leave to enter this country, not necessarily to work or stay. Treachery? Is that betrayal by the UK?
	The extracts go on to say that,
	“this is not just an issue of government policy. It’s also about the messages propagated by the media”.
	One of the students wrote about the Leveson report on press standards, which covered the media’s influence over community relations:
	“the report found that, in the tabloids particularly, ‘there are enough examples of careless or reckless reporting to conclude that discriminatory, sensational or unbalanced reporting in relation to … immigrants and asylum seekers is a feature of journalistic practice … rather than an aberration’”.
	Another interviewee said that government officials were looking for him in Syria. He cannot communicate directly with his family. He said:
	“London is like a desert to me. I don’t speak the language. I don’t have any contacts. I am alone. Like in a desert, but filled with people around me”.
	The writer of the article said that she would not know how refugees express gratitude and asked the interviewee if he would answer the question: should we expect Syrian asylum seekers to be grateful? He said:
	“I am lost here, my life is in Syria. I was forced to leave. But Britain has been like a caring mother to me, and has given me everything. Britain has given me rights again. Britain is educating me. I am grateful”.
	Last night, in response to a request for some comments about his experience here, another young Syrian wrote to me about the difficulties—it was not anything that I had expected. He explained his experiences with great understatement. His family decided to leave because,
	“the situation was very horrible and a lot of bombs fall”.
	He said that,
	“the most difficult thing is the feeling when you must leave your country and you cannot return to it”.
	I think his English is brilliant. He said:
	“The most difficult thing here is the miss for the country, the family, and the friends, and really it is very hard when you hear that one of your best friends is dead and this happened with me more than ten times. I want to say thanks for the British people and for British government to receive us and to give us the support to survive and complete our life but in same time you should to know that about one million of the Syrian has same my situation and they need your support and help. The first rule in my life is you can achieve your dream when you trust with yourself”.
	We pride ourselves on our history of welcoming those who seek refuge here, and those expressions of gratitude really make you think. As my noble friend Lord Maclennan said, we should be taking a leadership role in a global society because we live in a globally connected world.

Lord Collins of Highbury: My Lords, I, too, thank the noble Lord, Lord Alton, for initiating this debate and for reminding us that more people are displaced from their homes than at any time since the Second World War. As we have heard, today there are almost 60 million displaced people in the world. The war in Syria alone has produced 4 million refugees, making it one of the biggest refugee crises on record. Millions more are displaced inside the country.
	It is right that we have a debate on immigration and the state of affairs within our own borders. But we also need to promote a broader discussion that examines the causes and the responses by the world community to mass migration. As the noble and right reverend Lord, Lord Harries, said, we must begin to establish the values that should guide our response to a refugee crisis fuelled by climate change, political unrest and conflict. We must also acknowledge that, in some situations, these two debates are linked and that previous interventions undertaken in our name have undeniably fed the current turmoil.
	The world’s focus must be on finding political solutions to the cycles of violence that drive civilians from their homes, and on breaking the culture of impunity that has come to characterise brutal conflicts such as those in Syria and South Sudan. Each new tragic incident—the seizure of Yarmouk, the shipwreck off Lampedusa and the desperate plight of the Rohingya—is more horrific than the last, and must spur political action.
	Strict quotas, such as those set out in the European Commission’s proposed agenda on migration will not work, but the lack of solidarity shown by this Government is immoral, in my opinion. In such situations, ours
	should be a generous response, not a constrained one. As the noble Lord, Lord Luce, highlighted, 86% of refugees reside in developing countries. Conflicts and crises occur most frequently in poorer countries. They occur and people are compelled to cross the nearest border. Refugees often have social, economic and cultural bonds with neighbouring communities and they may prefer to remain close to home.
	The UK, as we have heard, is one of the top donors to Syria and the region. It goes without saying that it is vital to support refugees where they are. Governments, donors and NGOs must take a long-term view, as many refugees will be resident for years and even decades. That also means making sure that support is given to host communities, which are often just as poor and under immense strain, as well as to the refugees. That was highlighted by my noble friend Lord Judd. By resettling more refugees, we not only offer a lifeline to some of the most vulnerable people but it will give us a greater moral authority when we call on countries such as Lebanon and Jordan to keep their borders open and uphold the rights of refugees.
	The Government’s decision to halt the paring back of search and rescue operations by the use of HMS “Bulwark” was welcome, but does its replacement by HMS “Enterprise” signal a reduced commitment by the UK in the Mediterranean? Can the Minister explain how the Government expect HMS “Enterprise” to undertake its dual operational functions of refugee rescue and the apprehension of smugglers? I fear that the response of Mr Brokenshire, the Minister, to your Lordships’ sub-committee, which was reported in the media yesterday, will only confirm to the rest of the world the UK’s continued reluctance to engage.
	With regard to the Syrian conflict, the Prime Minister has announced a modest expansion of the UK’s resettlement programme, particularly for vulnerable Syrian refugees in the region. Can the Minister provide more detail on how many more places will be available? Of the numbers accepted from Syria, can the Minister also tell the House how many were already in the UK, including students?
	My party’s view is that Britain should rejoin the United Nations official refugee programme for the most vulnerable refugees, understanding that many of these migrants will not even make it to a boat or get here on a plane; they will die in a camp without our help. There are close to 3 million refugees in sub-Saharan Africa as a result of violence and fighting in South Sudan, the Central African Republic, Nigeria and elsewhere. In the last few weeks, political tensions in Burundi have pushed tens of thousands into neighbouring countries, including the Democratic Republic of the Congo, which itself has close to 3 million internally displaced people. The conflict in Yemen has been so destructive that thousands of Somali refugees and other nationalities who had escaped there are now seeking safety in Somalia, even though that country continues to experience violence.
	No country or region is immune, from Libya and the shores of the Mediterranean, through to the Gulf of Aden, and across the sea, where the Rohingya and Bengali families were stranded on boats for months with scarce food and water. The Prime Minister has
	emphasised that those people fleeing to Europe across the Mediterranean were being driven—pushed—to attempt these journeys, highlighting failed states and people smugglers as the drivers. However, what he failed to mention, which we have heard in this debate, is the persistent and widespread human rights abuses directed at their people by brutal regimes such as Eritrea, and the unsustainable demands being made on countries such as Jordan and Lebanon in trying to accommodate refugee populations.
	UK Ministers, as highlighted by James Brokenshire’s remarks, suggest that resolving the Mediterranean crisis is dependent on breaking a mythical link between boarding a boat and settling in Europe. However, as we have heard, the great majority of those attempting the Mediterranean crossing set off from Libya, a country experiencing a vicious internal conflict. Refugees and migrants have suffered appalling abuses. The contention that these immigrants are “economic migrants”, rather than desperate victims of human catastrophe, is inaccurate and alarming. If we are to have an honest debate, we need strongly to challenge this contention. António Guterres, the UN refugee chief, stressed that most of those attempting the journey are not economic migrants: a third came from Syria, while people fleeing violence in Afghanistan and Eritrea’s repressive regime each made up 12%. Other countries of origin include Somalia, Nigeria, Iraq and Sudan. The British people, who are understandably concerned about levels of migration, are more anxious about human decency when confronted with the facts.
	My right honourable friend Yvette Cooper said that we should decouple asylum from migration targets. It skews the debate and frames an issue of decency in the context of political expediency. Refugees should be removed from the net migration target. Our aim should be an integrated development, defence, foreign and home policy that recognises that the global challenges we face are interconnected. It is therefore a matter of concern that the Department for International Development has been excluded from a number of cross-Whitehall committees, including the National Security Council and the immigration task force. That represents further isolation and fading influence.
	We were once a nation that was proud to offer a place of sanctuary for people fleeing horrific rights abuses worldwide, but the Government’s deliberate retreat from the world stage has put our reputation at risk. The UK must stand up for the world’s least wanted people, but we must do so in a manner based on sound principles and which requires consensus. It is a debate whose urgency cannot be underestimated.

The Earl of Courtown: My Lords, I thank the noble Lord, Lord Alton, for securing the debate. I commend him on his long-standing engagement on international development and foreign policy issues. I also congratulate all noble Lords who have taken part in the debate, which had a particularly impressive speakers list. I shall try to answer all the questions that have been posed. If I fail to, because I am very pressed for time, I shall write to noble Lords and put copies in the Library.
	As other noble Lords have said, we have all been shocked by the plight of migrants dying on an unprecedented scale on boats in the Mediterranean and in the Andaman Sea. People are fleeing war, violence and deep-rooted poverty. The collapse of authority in Libya has meant a huge increase in numbers coming through the central Mediterranean. Addressing these issues requires a complex and far-sighted response.
	At a special meeting of the European Council in April, it was agreed that we had to act to address the humanitarian tragedy unfolding before us. At that point, the UK contributed HMS “Bulwark”—to which tribute was paid by the noble Lord, Lord Alton, and other noble Lords—to support the Italian rescue effort. She has rescued more than 4,700 people from sinking boats that have set off from Libya.
	We have also provided two Border Force cutters to support the search and rescue operations, and to date they have rescued some further 450 people. In total, UK vessels have rescued more than 5,000 people from drowning. But we also agreed that we could not resolve this crisis without a long-term comprehensive approach. This is where we need to work together across Europe to tackle the drivers of this migration.
	The noble Lords, Lord Collins and Lord Alton, the noble Baroness, Lady Kinnock, the noble and right reverend Lord, Lord Harries of Pentregarth, and many other noble Lords expressed their concern about HMS “Bulwark” returning home and being replaced by HMS “Enterprise”. We have always been clear that to tackle the migrant crisis we need a comprehensive plan in going after the criminal gangs, smugglers and the owners of the boats, potentially taking action there as well, and stabilising the countries from which these people are coming. So it is right that we now move to the next stage under the CSDP’s mission. As a multirole survey ship, HMS “Enterprise”, as mentioned by the noble and right reverend Lord, Lord Harries, is well placed to assist in this phase of the operation, particularly given its additional intelligence-gathering capability. We can do this now because other European partners are stepping in with contributions to the CSDP operation.
	The noble Lord, Lord Collins, suggested that our United Kingdom contribution was decreasing. This is not the case. As well as HMS “Enterprise”, there is another helicopter attached to this operation and two Border Force cutters—HMC “Protector” and HMC “Seeker”—are aiding FRONTEX’s Operation Triton. In addition, we have contributed a further five defence personnel to the multinational operational headquarters in Rome, which is crucial to establishing the CSDP mission.
	The urge to migrate and to seek a better life is a natural human instinct. It is part of a broader process of global change and development and a route out of poverty for millions. However, we must seek to manage irregular migration in a rational way, addressing its root causes as well as its short-term impact. Some people will be fleeing war and persecution, others are economic migrants seeking a better life. We need to make a distinction between these to ensure we address the root causes of this migration.
	In the short term, we are providing humanitarian support to refugees and displaced people across the world. The Government have just provided a new humanitarian package of support, with an additional £100 million pledge to Syria, taking our public commitment to £900 million to date. This is our largest-ever response to a humanitarian crisis and makes the UK the world’s second-largest bilateral donor to the Syria crisis. It is providing food, clean water, medical care and other essential aid that is helping hundreds of thousands of people in Syria and its neighbouring countries and is having a big impact on reducing people’s need to flee the region.
	The Government have also just announced an additional £217 million to Africa to provide support to more than 2 million refugees who are displaced across the region. There is also a new £110 million programme for work in the Horn of Africa, with a focus on refugees in Ethiopia and Sudan. The UK is now the second-largest bilateral donor in the Horn of Africa in providing humanitarian support for displaced populations. As the noble Lord, Lord Alton, and the noble Baroness, Lady Kinnock, said, on the other side of the world, Rohingya refugees have fled their homes in north-west Burma. The United Kingdom is one of the largest donors in Burma, providing £18 million in humanitarian assistance since 2012 to Rakhine State, from where many of the Burmese Rohingya found on boats in the Andaman Sea originate.
	We are also tackling the networks that lie behind people-smuggling. This form of illegal migration funds organised crime and undermines fair immigration controls by allowing economic migrants uncontrolled access to our countries. This emphasises the importance of our supporting the creation of a credible national Government in Libya who can work with us to secure its coastline.
	We must also develop a much richer picture of how these networks are exploiting people, so that we can disrupt them. The Government are establishing a dedicated law enforcement team to tackle the threat posed by illegal immigration from north Africa, in light of the surge in numbers crossing the Mediterranean. This will bring together officers from the National Crime Agency, Border Force, Immigration Enforcement and the Crown Prosecution Service, with the task of relentlessly pursuing and disrupting organised crime groups profiting from the people-smuggling trade. We will work with our international partners to identify organised crime groups smuggling migrants to the Libyan coast; illuminate the routes and methods the smugglers use; and understand the money flows. These insights will be shared with our partners to disrupt those orchestrating the smuggling.
	At the same time, we must be clear that we will meet our obligations to provide refuge for the most vulnerable. The United Kingdom already participates in the United Nations programme to resettle refugees who have fled from their home countries, including those affected by conflict or civil war. We also set up our own scheme for particularly vulnerable people fleeing the conflict in Syria, including women and children at risk who could not be protected in the region. However, these are only short-term measures. These scenes demonstrate how working with developing countries not only matters to them but, more than ever before, matters to us too.
	We must work together to tackle this issue upstream at source, as mentioned by the noble Lord, Lord Griffiths of Burry Port.
	In the long term, development assistance addresses the root causes of instability and insecurity, reducing inequality and providing economic opportunities for all. This helps to build more effective states and societies, reducing some of the pressures to migrate. Finding the means to support stability, prosperity and opportunity means a more stable and prosperous world for us all.
	The United Kingdom is already refocusing its own efforts. Despite the difficult economic times, Britain has kept its commitment to spend 0.7% of GDP on aid. The United Kingdom will spend over £4 billion on bilateral and multilateral development assistance in Africa this financial year. Of this, £725 million will go bilaterally on development programmes to key source and transit countries for irregular migrants in the Horn of Africa and east Africa. We will also spend £280 million bilaterally on governance and security, building state capacity to achieve stability, peace and respect for human rights; and £540 million will be spent bilaterally on economic development, including a strong focus on jobs and urban youth populations, particularly relevant in areas of the Horn of Africa.
	We are supporting the cross-government effort, including the £1 billion Conflict, Stability and Security Fund, which seeks to deliver longer-term peaceful political settlements—ultimately the best tool for reducing flows of irregular migration into the European Union from countries in the Middle East and north African region. At the Department for International Development we have already refocused our priorities to be more on jobs and livelihoods than ever before. Through United Kingdom aid we are investing a total of £1.8 billion globally on economic development this financial year, more than doubling the direct amount spent in 2012-13. This refocusing of our programme will take time to have an impact on the current migration trends.
	A number of noble Lords have mentioned the recent debate in the Moses Room, which my noble friend Lord Bates responded to on behalf of the Government. He has been pleased to write to all Ministers in this House from the Ministry of Defence, the Home Office—that is himself, of course—the Department for International Development and the Foreign and Commonwealth Office, so that all the Ministers in the Lords will be able to discuss these matters among themselves, and I will be taking part in these discussions as well.
	The noble Baroness, Lady Kinnock, and the noble Lords, Lord Alton and Lord Collins, went further on the problems facing the Rohingya people. The United Kingdom has taken action at ministerial level by raising the issue with the Burmese ambassador in London. We are issuing a joint demarche, with the US and the EU, to Ministers in Burma, and we are lobbying ASEAN member states Thailand, Indonesia and Malaysia not to turn away boats in distress. On 29 May, we participated in the Thai international co-ordination meeting as an observer. We call on all parties in Burma to address the dire situation of the Rohingya community in Rakhine state. We want to see improved humanitarian access, greater security and accountability, and a sustainable solution on citizenship.
	The noble Lord, Lord Alton, and my noble friends Lord Marlesford and Lord Higgins all mentioned the issue of safe havens. The scale of the present situation requires ambitious thinking. We must contemplate difficult decisions to help break the link between getting on a boat in north Africa and being allowed to enter and remain in Europe. Our colleagues in Spain have valuable experience in doing exactly this when migrants arrived in their thousands in the Canary Islands. We can learn important lessons from them, but we will be urging the EU to look to create safe zones in transit countries where illegal migrants could remain, or to which those who end up in Europe and who do not require asylum could be returned when it becomes difficult to send them home directly. For this reason, the United Kingdom is very interested in the proposal by the European Commission for a multipurpose centre in Niger. We have joined the informal working group to develop this and will be pressing for the level of ambition to reflect the need to fundamentally change the current patterns of illegal migration to the European Union.
	My noble friend Lord Higgins mentioned the situation in Calais. We recognise that we need to do more with our French counterparts to tackle the issue. My right honourable friend the Home Secretary and the French Interior Minister, Bernard Cazeneuve, set out a number of commitments in a joint declaration published last September to tackle the problems at the port. The declaration included £12 million from the UK Government towards upgrading the security infrastructure at Calais and other juxtaposed ports.
	The noble Baroness, Lady Kinnock, also mentioned asylum. The majority of illegal immigrants to Italy come from countries such as Nigeria, Ghana and Senegal where the drivers for emigration tend to be more economic rather than fear of persecution. My noble friend Lord Higgins asked what the European Union is doing. The EU needs to do more to ensure that it is taking a lead role in responding to this crisis. As the noble Lord, Lord Luce, said, working closely with the African Union is vital, and I welcome the proposed summit that is to take place in Valletta in the autumn.
	A number of noble Lords, including the noble Lord, Lord Griffiths, and the noble Baroness, Lady Kinnock, mentioned the human rights situation in Eritrea. The UK will continue to press Eritrea to improve its human rights record through a range of channels, including through our engagement with multilateral partners on their programmes. The root causes of migration from Eritrea are complex. They are driven by a mix of economic, social, political and other factors, but the opportunity for economic development is clearly a contributing factor that is clearly influencing people’s decisions to migrate.
	The noble Lord, Lord Maclennan, asked about resettlement. We have been clear that the United Kingdom will not sign up to a compulsory European Union quota system which risks undermining control of our own borders and the UK asylum system. However, I am proud of this country’s record for resettling refugees. In the past five years we have resettled more than 5,000 people, second only to Sweden in the European Union.
	The noble Baroness, Lady Cox, mentioned humanitarian aid in Sudan. The United Kingdom is a leading humanitarian donor in Sudan, with my department involved in a programme of £47 million in 2015-16. The majority of this is focused on the provision of humanitarian assistance. The noble Baroness also mentioned cross-border support in Sudan. While we are deeply concerned at renewed military activity in the two areas, we continue to judge the risks of providing cross-border support to be too high, due to the limited number of implementing partners and our inability to assess or monitor programmes. However, we continue to review this policy.
	My noble friend Lord Marlesford mentioned the £900 million response in Syria. The response to the conflict in Syria is the United Kingdom’s largest ever to a humanitarian crisis. As my noble friend said, the UK is the second largest donor to the Syrian crisis. This response also supports Lebanon, Jordan, which was mentioned by other noble Lords, and Turkey to deal with the influx of refugees and the pressures this creates.
	The noble Lord, Lord Luce, asked what we are doing in the regional development and protection programmes. These are EU-led initiatives to increase efforts to deal with what is called the stickiness of refugees in transit countries. This has two goals: to strengthen EU member states’ co-ordination and coherence and to develop activities to strengthen migration management in the region, and benefit refugees and migrants.
	The noble Lord, Lord Maclennan, also mentioned the Syrian relocation scheme. I understand that 187 people have been helped under this scheme. On Friday 19 June, my right honourable friend the Prime Minister announced that we would modestly expand the scheme by offering a few hundred more places by working with the UNHCR.
	I will now have to finish my notes. It is only through taking an approach that both addresses the immediate symptoms, through our search and rescue on the Mediterranean and our humanitarian programmes across Africa, the Middle East and Asia, and the root causes, through our long-term economic development and governance programmes, that we can truly have an impact. Through shared prosperity and ambition, we need to work to create a world in which people do not feel forced to leave their home countries.

Lord Alton of Liverpool: My Lords, without exception we have heard a series of hugely knowledgeable speeches, tackling a range of complex themes. I was particularly struck by the references made to imaginative ideas, which the Minister just described as ambitious thinking. In the 18th century that led, for instance, to the creation by Britain of a new city, Freetown, in Sierra Leone and in the 19th century to the creation of a new country, Liberia, to help those who were trapped in slavery at that time.
	Let me end by referring to the awesome courage, dignity and determination to survive of so many refugees and migrants. Just yesterday, I heard from a young
	North Korean who had been tortured, imprisoned and forced to scavenge on the streets. He escaped from a country where 200,000 are in concentration camps. After being given asylum in the UK and having had two years in a UK university, yesterday Timothy received British citizenship. His greatest desire is to use that freedom and education to return to his own country and help to rebuild it. That is the greatest longing of most refugees and I hope that today’s important debate will give encouragement to those such as Timothy who read it. I reiterate my thanks to all noble Lords who have taken part.
	Motion agreed.

Mental Health Services in Schools and Colleges
	 — 
	Question for Short Debate

Lord Storey: To ask Her Majesty’s Government what proposals they will bring forward regarding mental health services in schools and colleges.

Lord Storey: My Lords, I think that this is the fourth or fifth time in almost as many days that we have talked about mental health, which perhaps shows how important the matter is to your Lordships and that there is a need for action. No doubt there has been and will be repetition in what we all say but, again, that tells me how important the issue is. I also put on record my thanks to the numerous organisations that feel passionately about the issue and have sent a whole series of briefings.
	Despite having one of the most advanced health systems in the world, child health outcomes in the UK, including for mental health, are among the poorest. Just 6% of the NHS budget for mental health is spent on children and young people. I know we have heard them on a number of occasions in the various Questions and debates, but we should remind ourselves of some of the facts. One in 10 children and young people aged five to 16 suffer from a diagnosable mental health disorder, which equates to three children in every classroom. One in every 12 to 15 children and young people deliberately self-harm, and nearly 80,000 children and young people suffer from severe depression. Alarmingly, all these figures are on the increase. Yet despite these figures, a freedom of information request from YoungMinds sent to every NHS clinical commissioning group and every upper-tier local authority in England found that 74 out of 96 NHS clinical commissioning groups have frozen or cut their CAMHS budgets in the last two years, while 56 out of 101 local authorities in England that supplied information to YoungMinds have cut or frozen their budgets, or increased them by less than inflation, during the same period. We ignore the situation at our peril.
	Half of those adults with mental health problems had symptoms by the age of 14, yet there is little urgency in getting a child into treatment and support.
	What needs to be done? We all recognise that early intervention among schoolchildren is so important in helping to identify and address potential mental health issues. We need to ensure that every teacher has some form of professional development training to help them understand the problems and recognise the possible symptoms. This is not difficult and costs next to nothing. The Department for Education should include a mandatory module on mental health in its initial training, with mental health modules forming part of ongoing professional development in schools for all staff. Would the Minister consider a request to discuss this matter with her noble friend the Education Minister?
	We need to have a school and college referral system which is fit for purpose. These young people’s lives are too important for them to be pushed from pillar to post. The SENCOs—the heads or co-ordinators of special needs in schools and colleges—need the training and the ability to refer cases speedily. Those referred should not have to wait for months and months to be seen. What does the Minister think is the minimum time within which a pupil or student who is referred should be seen by a professional? You would not expect somebody who is diagnosed with, say, cancer to wait months, let alone weeks, before they are treated.
	I said that early intervention is crucial. The transition from school to college is complex and is when many health difficulties often arise: examinations, employment pressures and of course the influence of social media can all contribute to mental health issues. I was grateful to the Association of Colleges, which sent me the results of a recent survey it carried out. Of the 123 colleges which responded, 67% said the proportion of students with disclosed mental conditions had significantly increased year on year over the last three years. Alarmingly, 100% of colleges that responded said they had students who self-harm and have depression or anxiety. Worryingly, 60% of the colleges that replied to the survey did not even have their own college mental health policy. That is not difficult to do.
	Then, of course, there are some fantastic examples of good practice in our colleges. Take Highbury College in Portsmouth: for several years it has developed its programmes and support for students with mental health conditions. As one student said:
	“It helps me to believe in my own ability—I hope that I will be able to achieve things better in future. I’m a student again, and not just a mental health service user”.
	Hackney Community College has developed mental health services since 1997. It is a beacon of best practice than can be disseminated to support the work of other partnerships. In my own city, Liverpool Community College works closely with the local authority and commissioning boards. Will the mental health prevalence survey include 16 to 18 year-olds as well?
	Of course, for many young people education is not just building-based and many will be in educational training. That includes apprentices or trainees. They may not realise they are developing mental health problems and may be afraid of what is happening to them, not having the understanding, language, insight or ability to tell others what they are experiencing. Friends, parents or carers may not have experience of mental health problems and may not realise or recognise
	that they are developing them. We need a co-ordinated and joint approach between the Departments of Health, for Education, and for Business, Innovation and Skills, issuing guidance to learning providers and employers about their roles and responsibilities to apprentices and trainees regarding their mental well-being. An 18 year-old should have access to the same quality of service whether they are an apprentice or full-time undergraduate.
	When the Children and Young Families Act passed through your Lordships’ House, one of the many issues that drew concern was that of young offenders, which we also talked about when discussing the secure college. In the debate, we discovered that 80% of young offenders had special educational needs and 20% were on statements, as they were then called. Also—I did not realise this—95% of imprisoned young offenders have a mental health disorder and many of them struggle with more than one disorder. Just think how their lives could be turned round with proper mental health interventions.
	Finally, I again highlight the issue of children in care. A staggering half of looked-after children in England and Wales have a diagnosable mental health disorder—four times higher than the figure for the general child population. I was very taken by a report from the NSPCC, which had worked with local authorities and their health partners to explore how we can improve mental health support for children in care. That report makes important reading. In particular, it argues that rather than being the responsibility of only specialist services, every professional working with looked-after children should understand what they can do to support their emotional well-being resilience. I am absolutely sure that there is a real will and determination to ensure that children and young people with mental health and well-being disorders are given the maximum support, that early intervention becomes the norm, and that professionals are fully trained so that these young people can thrive and prosper, and enjoy their lives to the full.

The Earl of Listowel: My Lords, I thank the noble Lord, Lord Storey, for tabling this debate. Of course, he has a lifetime’s professional experience in this area and we heard that in what he said.
	I begin with his final point, on the mental health of looked-after children and the NSPCC report that he referred to. The Minister may recall from our discussions on early years childcare recently the emphasis put on high-quality early years care and in particular the discussions on the importance of a secure attachment between mother and infant, and of the nursery guarding that secure attachment. Relationships in that early period are key to the mental health and success of these children. What we hear from children in care who have not had that experience is that it becomes vital for them to have a stable foster placement, adoption placement or residential childcare worker and to stay in the same school and build a relationship of trust with an adult who is interested in their welfare over time. The NSPCC report and other reports on looked-after children emphasise that children who enter care have been traumatised. Care’s purpose should be to help
	them recover from that trauma and, fundamental to that, is the relationship with the people they value most in their lives—their foster carer and so on. The aim of the health service should be to support that relationship between the teacher and the looked-after child, the foster carer and the young person—although it is important to provide therapy directly to the child—by providing expert support to the parents, social workers and residential childcare workers.
	I shall speak about interventions to prevent children needing mental health services in schools and about an important intervention that can be made. I am a patron of a charity called the Institute of Recovery from Childhood Trauma. It had one of its regular seminars yesterday. Dr Robin Banerjee of the University of Sussex showed a diagram that highlighted that the more popular a child is, the better their mental health and the better they do in school. It also showed that the less popular a child is, the poorer his mental health and the less well he does in school. He developed a project with the Mulberry Bush School, of which the Prime Minister is patron, looking at how creative activity can strengthen the bonds between children in school and therefore help unpopular children to manage relationships better and become happier and more successful. It has had very positive results.
	I have emphasised the importance of relationships with their peers in stopping children becoming ill, and now I shall concentrate on relationships with adults, particularly teachers but with the whole staff of the school. They are very important in protecting children against poor mental health. The evidence is very clear about the importance of resilient relationships with teachers. Finland is often held up as a great example of an education system. An interesting facet is that from the age of seven, when children start school, they have the same form teacher to the age of 14, I think, but it might even be later. For seven years, they have the same teacher in their lives. It was a great pleasure recently to talk to a Finnish migrant to this country about her experience. She spoke about her affection for her form teacher, whom she knew throughout her development, and the fact that her teacher knew her so well.
	To step aside for one moment—I shall come back to this—there is real concern about setting boundaries for young people. If you talk to head teachers, they will talk about the change in our culture. Years ago, if they punished a child, the parents would be right behind them. Today, very often, if they punish a child, the parent will say, “Why are you picking on my child?”. Children and young people going into the criminal justice system often have never had proper boundaries set for them. They do not know what is right or wrong. It is far more effective to have boundaries set by someone one loves than by someone one just fears, so a teacher, a prison officer or a residential childcare worker who has developed a bond of affection and trust with a young person is in a much better position to say, “No you can’t go out tonight”, “No you mustn’t mix with people like that” or “No you shouldn’t drink”, than someone who does not really know them and has to use force and fear to get them to do what is necessary.
	I encourage noble Lords to think back to their own schooldays. In my own experience at primary school there was Mrs Dunon; she was beautiful and intelligent, and I was absolutely infatuated with her. I still remember today her pointing to the ring on her finger and explaining to us that by heating the ring up, the atoms vibrated faster, the ring expanded and she could remove it from her finger. I do not know whether that started my love of science, but I certainly developed one over time. I then think back to my science teacher, Mr Brown, and particularly my housemasters, Mr Woolett and Mr Jones-Parry. Mr Jones-Parry was an exceptional teacher and was wonderful in setting boundaries for us. I encourage your Lordships to think about their own relationships with teachers and how important they were in terms of their emotional well-being and in setting boundaries.
	I turn to the intervention that I spoke of. This is the consultation and liaison model that is referred to in the Future in Mind report that the Government commissioned. I pay tribute to the charity YoungMinds, of which I am a patron, and which was very much involved in that report. The chapter dealing with the most vulnerable children talks about this liaison and consultation. To paraphrase what it says, often the most effective way to help children with the most complex needs is to have the best professionals working with staff members on building a relationship with the child, so the foster carer, social worker or whoever gets help from a child psychotherapist or clinical psychologist. I shall give your Lordships an example of this: when Emil Jackson, a child psychotherapist, was at the Brent Centre in north London, he provided such a consultation and liaison service to 10 schools in Brent. This meant that school staff—not just teachers, but all staff—could attend seminars and consultations every two or three weeks, and for an hour or two they would take it in turns to present a particular child, talk about their relationship with that child, have the other professionals in the school group help them to think about their relationship with that child, and have that discussion facilitated by Emil Jackson. He found, first of all, that head teachers found it made a real difference to the culture of the school and, secondly, interestingly and importantly, this particular group had a lower sickness absence rate than the rest of the school.
	The principal reason for teachers leaving teaching is because they have difficult relationships with their children. If one had this sort of excellent support for teachers, our valuable and experienced teachers would be more likely to remain in the profession. That is another reason why this approach is really important. I remember speaking to a former Teach First graduate—Teach First teachers went into the toughest schools—who said how much he wished they had had that kind of support to help them to manage those kinds of relationships.
	I emphasise the fact that we need to support children in their relationships if we want them to be healthy. I am really concerned about the increasing numbers of children growing up without a parent in the family or with one absent parent. When I worked with children I found that I was befriended by boys because they had no father figure in their lives. We need to think about how to engage fathers and keep them engaged, and how to find good male role models where there is no
	father. I wonder whether Ofsted might be charged with looking at all children’s services, schools and others, to see how effectively it could engage fathers and, where fathers are not available, provide good male role models who would be well supported to make relationships with children who do not have such good male role models in their lives. I look forward to the Minister’s response.

Baroness Tyler of Enfield: My Lords, I am very pleased that children and young people’s mental health is garnering so much attention in your Lordships’ House, and I congratulate my noble friend Lord Storey on focusing our attention this afternoon on mental health provision in schools and colleges. I declare an interest as vice-president of the charity Relate, which provides counselling to children and young people in various schools, children’s centres and GP surgeries.
	As we have already heard, schools have a critical role to play in supporting pupils by promoting positive mental health and emotional well-being as part of their overall school ethos, as well as spotting and addressing minor problems before they escalate, and helping to connect pupils who have more serious problems with the more specialist help they need. We know that 75% of adult mental health problems emerge before the age of 18, and in recent debates in this House we heard about the difficulties that children and young people face in school such as bullying, relationship and family problems, the impact of domestic violence in the home, academic stress and other things that often trigger or exacerbate mental health problems, including self-harm. Why is this issue so pressing? My noble friend Lord Storey set out the key statistics, so I will not repeat them. However, I will just mention, picking up on what the noble Earl, Lord Listowel, said, that 72% of children in care have behavioural or emotional problems.
	I want to acknowledge that in recent years we have seen progress in embedding a commitment to positive mental health within schools. It is encouraging that over 90% of schools now address mental health and well-being in the personal, social and health education curriculum, and that a similar proportion also do so in other lessons—a point I will return to in a minute. This past spring, the Department for Education has published new guidance for the PSHE curriculum and an evidence-based counselling strategy that encourages the use of counselling in schools. Moreover, the new draft Ofsted framework Better Inspection for All includes a new judgment on personal development that will help ensure that schools will be held accountable for providing good mental health services.
	However, despite all these good things, much more work still needs to be done to ensure that all students are able to access good mental health services in schools. Research from the think tank CentreForum published late last year shows that 86% of secondary schools provide access to a qualified counsellor—which in some ways sounds quite good—but provision is patchy. For example, special educational needs schools are much less likely to provide counselling than mainstream, maintained schools, even though children with SEN are more likely to have mental health problems.
	In addition, as the British Association for Counselling and Psychotherapy has pointed out repeatedly, England lags behind Northern Ireland and Wales in providing access to counselling for all secondary students. The simple reason for that is primarily because there is a statutory requirement in Wales and Northern Ireland for local authorities to provide school-based counselling in all secondary schools. In short, it is not seen as an optional extra. What plans do the Government have to ensure universal access to school counselling across England?
	Work must also be done to make these services more widely known and welcoming to students. Only about half of schools advertise or promote their services, and perhaps as a consequence, according to the charity YoungMinds, which does such excellent work in this area, one-third of children report that they do not know where to turn for mental health support. This must be a matter of real concern for us all. Equally worrying, there is evidence to suggest that children who belong to various minority groups are less likely to take up school-based counselling. Schools could learn a lot from successful examples from the voluntary sector about how to encourage take-up of school counselling among children who need it, particularly in a non-stigmatising way.
	Moving on, these measures are most effective as part of a whole-school approach to good mental health and well-being. Part of this means that school staff must be equipped with the skills and feel confident to identify students who are having difficulties and to provide some level of support. Yet, according to CentreForum—a point already raised by my noble friend Lord Storey—there is no mental health and well-being training in 17% of mainstream maintained schools. Can the Minister say, either now or perhaps by letter, what plan the Government have to act on the recommendations of the CentreForum report and the recent Carter review of initial teacher training, and improve training for teachers on mental health?
	Of course, in some cases the services within schools will not be enough to tackle the challenges that children with mental health problems can present. So it is critical that children who need them are quickly and effectively referred to CAMHS services, and it is equally critical that CAMHS services are resourced to respond promptly—something which has been spoken about many times in your Lordships’ House but which patently is not happening.
	While the vast majority of schools have a referral pathway in place, only half of these were referred to in the CentreForum report as being effective. More concerningly, schools typically do not have the resources to properly determine when students need to be referred to a specialist service. Indeed, CentreForum found that only about a third of schools used screening tools to gauge the severity of need of their pupils. For that reason, I very much welcome the Department for Education’s proposal for a pilot programme that will place a CAMHS contact in 15 schools across the country to help develop good communications and links between CAMHS, school staff and students. If implemented effectively, this programme has the potential to provide more direct entry points into specialist
	mental health services and, equally importantly, to allow school staff to gain real insight into how to cultivate a healthy learning environment. Such joined-up thinking is key in giving children the support that they need.
	At the same time, as others have already said, we need to focus on prevention and early intervention—in short, how we should promote positive mental health for children and young people. We really do need a joined-up approach across government here. At present, the Department for Education promotes mental health support as a form of early intervention and as part of the broader goal of emotional and academic development—something that I support—while the Department of Health uses a more medical, diagnosis-driven approach that requires children to be diagnosed to a certain level in order to receive support. While having increased contact between CAMHS and schools, as I have just referred to, may help identify children who already have pressing mental health issues, we should be wary of applying this very medicalised approach to every student.
	I also ask the Minister what conversations are taking place between the Department of Health and the Department for Education about the best ways of marrying together these rather different approaches to children’s mental health and well-being. Given the expertise that resides in this House on the issue—as we have heard this afternoon—would it be possible to convene a meeting with both departments and a few of the noble Lords who have spoken in this debate to discuss further how these rather different approaches can best be reconciled?
	Of course, the 16 to 18 year-olds with mental health issues include a large number of young people studying in FE colleges, and it is really important that they are part of the equation. I shall not repeat what my noble friend Lord Storey has already said about this area but FE must be central to a mental health strategy moving forward. I join my noble friend in calling for FE students to be included in the prevalence study that the noble Lord, Lord Prior of Brampton, outlined to this House on 23 June.
	It is clear from today’s debate that schools and colleges have an indispensable part to play in promoting good mental health. This means providing accessible services such as counselling in all schools and colleges, and ensuring that the PSHE curriculum is taught effectively in all schools, irrespective of their status. For my money, that must include academies and free schools. I would like to ensure that high-quality sex and relationship education—which has just been referred to by the noble Earl, Lord Listowel, and which is so important for positive mental health and emotional well-being—is integrated within the provision of counselling in schools and statutory PSHE. That is something that we have called for from these Benches on many occasions.
	In conclusion, despite the progress that we have heard about and which I very much welcome, there is still much to do. The life chances of many pupils and students depend on these services and we must not let them down.

Lord Addington: My Lords, this is one of those debates when you realise that just about everything that you were going to say has been referred to and that, in the case of my noble friend and the noble Earl, much of the heavy lifting has already been done. So I simply say that it is quite clear that this is a real problem which we have probably underestimated for generations. The linkage between failure in life and education and mental health problems is absolutely clear but we really have not brought the two together.
	Much of my interest in education has been driven by the problems for certain groups in the special educational needs sector. We have established that these groups are even more vulnerable than the rest of society to mental health problems, almost certainly due to the greater stress that having these problems can cause within the education system. Take dyslexia, the one that I know best. If a child with dyslexia is placed in a classroom, they are placed in a situation where they are bound to struggle with the basic building block of our education—that is, the acquisition of written language. We then wonder why they acquire a greater stress level that leads to problems. Those problems might have been there anyway, but they are exaggerated and exacerbated by the entire system—it is almost inevitable. However, as was referred to by the noble Earl, Lord Listowel, if a parent intervenes early and does something about it, everything is great.
	How does this relate to mental health problems? Here, once again, the parent is the linchpin. If a parent identifies problems and moves around between services, they will, at the moment, get a reasonable outcome. The problem is that most parents do not know. We then come back to who else might spot this—it will be either a doctor or a teacher. However, when we go to the doctor, do they look for mental health problems? They are probably better than they were, but I imagine that the average GP will look to physical problems first. Can teachers do this job? Teachers become the poor bloody infantry of every problem facing the under-18s. They are required to intervene, know, get on with everything, identify and bring together. The least we can do is give them some form of basic training about the recognition of problems. This applies to special educational needs and will apply equally to this sector. If experts are built in to the education structure, teachers—when I say teachers, I mean every educational professional, right up to university level; it would not hurt—can refer young people on to the expert. If we do not do that, we do not have linkage points and are relying on the good luck of the parent involved being prepared to admit that their child has a problem. How many parents want to admit that? How many will try just about anything to avoid that? They have to be given support.
	Basic awareness packages do not take for ever to implement and are not the most expensive thing ever to be placed in schools and colleges, but there is always room for another one. We must look at increased amounts of time for training for those involved in the process. If we do not, we will build up an expectation that cannot be delivered.
	Legally, that duty is already there. The Children and Families Act is almost a year old now. I hope that, when looking at the implementation of the Act, we will get some guidance on special educational needs and the accessing of plans. It is something that was almost universally accepted, if not universally praised, when it went through. Have we identified where the problems are in getting the plans that call for all these bodies to work together? There will be problems; it would be ridiculous if there were not. We would not have passed the legislation if there was not the potential for problems—at least I hope we would not have. I hope that, when she answers, the Minister will give us some idea how the Government have looked at and indentified these problem areas. How do the pockets of expertise and excellence relate to the rest of the system? How do the various bits go together? It is quite clear that this is about linkage and moving through because, to refer back to my original point, if somebody fails in education, it is very likely that they will fail in the rest of their life.
	The Children and Families Act says that anybody with special educational needs or problems should be educated until the age of 25 to catch up. Once again, that was almost universally accepted. What are we doing to make sure that, in those extra few years, we actually are doing this? Are we making sure that we are bringing people together and making those links? Without it, we are wasting that person. We are turning them from someone who is an economic good for society to someone who is a drag on it, and making their own life just that little bit more unpleasant—if not, in some cases, unbearable. We have to do something here; it is about bringing the points together.
	If we fail, we are making our own lives that little bit worse. If we succeed and bring together those people who have shown a great interest in this field to look at the system, we make things a little bit better. We do not want to waste the people; we do not want to waste the time; we do not want to waste the money. Surely just by making sure that those services are co-ordinated and that people are a little better prepared to do what they are told by law they have a duty to do, we will make things a little better. I hope that the Minister will give us a good example of how we are co-ordinating services and developing models of good practice. Without those, I can see us having to address this issue again in legislation and having another long and boring battle over making sure that those services implement this. I hope that we do not have to, because I have a nagging suspicion that my life is far too short.

Baroness Jones of Whitchurch: My Lords, I am very grateful to the noble Lord, Lord Storey, for tabling this debate today and for enabling us to share our concerns about the lack of support for young people with mental health issues. I am conscious, as other noble Lords have said, that we have had several debates here on the broader issues in recent weeks, but it is useful for us to have the opportunity to look specifically at the educational aspects of the crisis. It is clear that we have the same concerns as other noble Lords and I may raise the same issues, but I hope that they will register with the Minister none the less.
	It is an issue that has forced itself on to my radar through the simple fact that it is so frequently raised with me when I have been out and about visiting schools. Teachers without any prompting, when I want to talk to them about other issues, want to talk to me about the stresses and strains that they experience when trying to deal with mental health issues among their pupils. There is a real sense of frustration and abandonment from them. They feel that they have been left alone to cope with increasingly complex cases, where in the past the children and adolescent mental health services would have stepped in to help.
	As noble Lords have said, schools are seeing a rise in mental health problems and a drop in available support. As the noble Lord, Lord Storey, and the noble Baroness, Lady Tyler, pointed out, there is also an alarming delay in getting access to professional help even when a problem has been identified.
	In a recent study conducted by the Association of Teachers and Lecturers, almost 90% of teachers said that they had had to provide more support for such pupils in the past two years, while 43% said that they were finding it harder to access services. The noble Lord, Lord Addington, made the point that teachers need more support, as responsibility seems to be falling increasingly on their shoulders at the expense of anyone else. But only 9% felt that they had been given enough training to help them spot the signs of mental illness, 43% said that the training was inadequate and 32% had received no training at all—again, a point that I know a number of noble Lords have already made.
	Noble Lords have given a number of examples of the rising incidence of young people’s mental health problems. Mention has been made of the report produced by the charity, YoungMinds, which showed that the number of young people with depression nearly doubled between the 1980s and 2000s. As the noble Lord, Lord Storey, said, one in 10 young people has a mental health disorder. In an average classroom, 10 young people will have witnessed their parents separate; eight will have experienced severe physical violence, sexual abuse or neglect; one will have experienced the death of a parent; and seven will have been bullied. It is becoming a more complex and stressful world for those young people.
	Then there are the more recent trends towards self-harm and eating disorders. During the past 10 years, the number of young people, mainly women, needing hospital treatment for an eating disorder has increased by 172%. These are some of the real challenges for the school and college community to manage, and so far we have not been doing enough to help and support them.
	Sadly, we have been dealing with the legacy of the previous education Minister, Michael Gove, who Paul Burstow, a former health Minister said recently was,
	“just not interested in mental health and wellbeing”,
	and I endorse that assessment. Obviously, I welcome the Government’s announcement in the Budget that mental health services for young people would receive an extra £1.25 billion over the next five years. There is a considerable amount of catching up to do since CAMHS have been starved of cash so long. I also
	welcome the Government’s report,
	Future in Mind
	, which includes some excellent first steps for improving school support. But more needs to be done.
	The point has been made consistently that early intervention is key. Many young people, for example, do not have the language or confidence to talk about their anxieties. The PSHE curriculum is an excellent forum for giving young people the understanding, resilience and life skills to cope with pressures in the modern world, so it continues to be a source of frustration that the Government are not prepared to make PSHE compulsory in all schools. Will the Minister indicate whether the current Secretary of State is prepared to review that decision?
	Does the Minister also see the advantage of counselling in schools as an effective early intervention strategy for young people, which can help to prevent mental health problems from developing? What are the Government doing to end the postcode lottery access to counsellors? Does she also agree with the point made by the noble Baroness, Lady Tyler, that we need universal access to counselling services in school?
	Does the Minister also accept that encouraging women’s sports and building body confidence can play an important role in boosting the health and self-esteem of young women? Does she share our frustration that the Olympic legacy has been squandered, with fewer young people doing sports at a senior level? What more are the Government doing to promote healthy living and fitness throughout the school curriculum, particularly in light of the recent public health cuts?
	At the same time, we could be doing more to educate young people about the physical changes that their brains undergo in adolescence. For example, during this time, the connections that develop empathy, rational thought, attention, concentration and judgment become more strained. Does the Minister agree that young people need help to understand their mental as well as their physical development? As the noble Earl, Lord Listowel, said, understanding the part played by role models and boundaries in adolescent development is really important.
	Does the Minister acknowledge that the Government’s obsession with passing exams is adding stress and anxiety to young people who are already struggling to survive in a complex and demanding world? Does she recognise that a strong cultural offering of art, drama, music and literature can often offer an important release for young people struggling with ways to express their identities and anxieties? What are the Government doing to put these subjects back at the heart of the curriculum?
	Will the Minister agree to revisit the mandate given to Ofsted so that it measures a school’s success in promoting emotional well-being as well as academic success? This should include evidence of a whole-school approach to mental health where children are encouraged to talk about their feelings and seek help when necessary, and where good relationships exist with counselling services, educational psychologists and CAMHS.
	The role of schools and colleges in enabling early intervention in mental health is absolutely critical. As has been said, more than half of adults with long-term
	mental health issues were diagnosed as children, but less than half received treatment at the time. The economic and personal cost of leaving young people’s mental health to deteriorate without support until it becomes an acute illness is vast. For every young person in a bed costing around £25,000 a month, we have to ask whether the money would not be better spent on early intervention and prevention. That should start with young people in schools. These are the challenges that face every Government, but particularly this one today, and I look forward to the Minister’s response.

Baroness Evans of Bowes Park: My Lords, I join others in thanking the noble Lord, Lord Storey, for securing this debate. As we have heard, this is one of a number on mental health issues that have taken place in the past few weeks, and I welcome the chance to concentrate on education and what we are doing to rise to the challenges set out in the Future in Mind report.
	Within the Department for Education, the Secretary of State has spoken about her own personal commitment to improving the mental health of children and young people. Last week she was at Upton Cross Primary School in Newham, looking at the work it does with Place2Be, one of the 17 voluntary organisations that are benefiting from nearly £5 million that the department is providing this year to support mental health projects. Place2Be works to provide early counselling support in a non-stigmatising way that is effectively part of the day-to-day life of the school, taking the whole-school approach the department has promoted through its guidance in this area.
	In further evidence of the Government’s commitment, Sam Gyimah was the first DfE Minister with a specific responsibility for mental health issues, and is continuing in this role. He worked very closely with Norman Lamb in the previous Government—I pay tribute to the work he did there—and is now working with Alistair Burt, the Health Minister, who has also made this area a top priority. Last Friday they appeared in front of the Youth Select Committee and next week are jointly hosting an event with stakeholders from across health, education and the voluntary sector about how to take forward Future in Mind. The noble Baroness, Lady Tyler, asked about organising a meeting between Members of this House, the Department of Health and the Department for Education. I am happy to take that proposal back to colleagues.
	As we have heard, schools and colleges play a key role in the lives of young people and in helping them become well-rounded, successful individuals in adult life. This means ensuring that students achieve academically but also helping them develop the attributes, behaviours and skills they need to get on in life. Qualities such as self-control and the ability to work well with others, to persevere, to have boundaries and to bounce back from adversity, coupled with values such as tolerance and respect, underpin future success and well-being. Schools and colleges have an important role to play in building this character and resilience, as well as promoting an understanding of mental health and respect for those with mental health issues.
	To support this, we have already invested £5 million in character education, including £3.5 million in grants to support 14 projects, and held a national awards scheme, which attracted 550 applications from all different types of schools. For example, Tapton School, a high-performing academy in Sheffield, has developed “Learner Levels” to track students’ progress in five key character traits: resilience, reflectiveness, reciprocity, resourcefulness and respect. Percy Hedley School in Newcastle, a special school for children with cerebral palsy and/or speech and language difficulties, has developed a variety of programmes focusing on social communication to develop a problem-solving and can-do attitude in pupils.
	I agree with the noble Baroness, Lady Jones, about the importance of PE and sport. The primary PE and sport premium ensures that primary schools focus on PE, and the Government have already provided more than £300 million of ring-fenced funding for the academic years 2013-14 and 2014-15. A full report on the impact of this will be published in the autumn but I can provide a taster of the key findings, which are very encouraging. For example, 91% of schools reported an increase in the quality of PE teaching; 96% reported improvements in pupils’ physical fitness; 93% saw improvements in behaviour; and 96% thought the funding had contributed to a healthier lifestyle for their pupils.
	The noble Baroness and the noble Earl, Lord Listowel, also highlighted how art, music, drama and literature can help young people with self-expression and identity. The Government strongly believe that every child should experience a high-quality arts and cultural education throughout their time at school. Art, design and music are all compulsory subjects within the national curriculum for five to 14 year-olds, and at key stage 4 all pupils in maintained schools have an entitlement to study an arts subject if they wish.
	Encouragingly, schools and colleges already recognise how good mental health can support success. A report published last December by the think tank CentreForum, which has already been referred to, found that 94% of secondary schools already promote positive mental health through lessons such as PSHE and drama or through school assemblies. In response to the noble Baroness’s question about PSHE, I say that we are considering the findings of the Education Select Committee report carefully and will respond in due course.
	However, we also recognise that not all teachers are confident about what to cover in mental health lessons and how to lead discussions. That is why we funded the PSHE Association to produce guidance on teaching about mental health, which was published in March. Example lesson plans for key stages 1 to 4 will also be provided to schools. These will cover age-appropriate teaching on how to describe emotions and talk about anxieties and worries. As children grow older, the curriculum will cover more specific teaching about mental illness.
	Of course, teachers are not mental health professionals and they need access to specialists and to be able to refer students quickly, when necessary. The Department for Education is contributing £1.5 million to a joint training pilot with NHS England to train mental health leads in education and specialist CAMHS to
	test how we can make professional links as effective as possible—an issue that has been raised by a number of noble Lords.
	As the noble Lords, Lord Storey and Lord Addington, highlighted, school and college staff need to know about mental health to be able to identify issues. While it is up to schools to decide what training their staff need, the Government have made sure that training is available for all adults working in schools. MindEd, a free online portal, funded by the Department of Health has been developed to enable adults working with children and young people to learn more about mental health problems and how to support them. Again, the CentreForum study found that 91% of secondary schools felt they had access to training for their staff. We want to encourage all schools to examine and take up opportunities.
	The noble Lord, Lord Storey, and the noble Baroness, Lady Tyler, asked about initial teacher training. As noble Lords know, Sir Andrew Carter chaired an independent review and the report was published in January. Following that, the Secretary of State has appointed an expert group to develop a framework of core initial teacher training content. This group is due to report at the end of the year and will consider the importance of including child development, as recommended by the review.
	Students value being able talk about issues and concerns in a safe environment, and as both noble Baronesses, Lady Jones and Lady Tyler, rightly said, school counsellor-linked services are often rated by both young people and school staff as an effective means of supporting mental health and emotional well-being, and a way of enhancing capacity to engage with studying. Most secondary schools in England offer access to counselling, where 50,000 to 70,000 sessions are delivered each year. The noble Baroness, Lady Tyler, asked about universal access to counselling in England and it is certainly our strong expectation that over time all schools will want to make services available to their pupils. That is why we worked with schools and experts, including Place2Be, to publish a blueprint for school counselling services in March this year, which provides schools with practical, evidence-based advice on how to deliver high-quality school-based counselling, and to raise awareness of such services.
	In our increasingly digital world, it is also important to help children to deal with online abuse, cyberbullying and websites that promote negative approaches to coping with issues. The new computing programmes of study, introduced in September 2014, ensure that e-safety is taught at all four key stages. The Government continue to make tackling all forms of bullying, including cyberbullying, a priority.
	The noble Baroness, Lady Jones, asked about Ofsted inspections measuring well-being and mental health. Changes to inspections from this September were announced in June. The new inspection handbook sets out that inspectors should evaluate the experience of particular individuals and groups, including those with mental health needs.
	It is vital that schools are given freedom to develop approaches that can best support their particular pupils. The capacity to innovate through the free schools
	programme is proving particularly valuable for young people with complex needs. For instance, both Stone Soup Academy in Nottingham and City Gateway in Tower Hamlets are alternative-provision free schools that bring together a range of support with a focus on getting disengaged and hard-to-reach learners back into education and training. Other developments are under way. For instance, the recently opened Family School, through collaboration with the Anna Freud Centre, is looking to incorporate the most up-to-date mental health practice in its provision for children with problematic behaviour.
	As the noble Lord, Lord Storey, said, further education plays a vital role in educating a large number of students aged over 16, many of whom are some of the most disadvantaged and who have complex needs. Colleges have considerable experience of providing the support students need to help them progress into employment and further learning. The noble Lord highlighted several colleges that are leaders in this area. On his question and that of the noble Baroness, Lady Tyler, about the mental health prevalence survey and whether it could include 16 to 18 year-olds, the answer is yes. It is still being put in place, but it should produce results next year.
	The Government are committed to helping our most vulnerable young people, which is why the Children’s
	Social Care Innovation Programme is providing £100 million to projects across the country to develop further effective ways to support children who need help from social care services, as highlighted by the noble Earl, Lord Listowel. Among the projects being undertaken are the Priory’s education services, which are working to pilot a new type of residential home; Action for Children, which is transforming the support available for teenagers in west London; and the National Implementation Service, which is helping young people to tackle problem behaviour and substance abuse, and prevent their entering care.
	The noble Lord, Lord Addington, asked about the SEN reforms. We have been working hard to identify problems faced by local authorities and to put them in touch with specific support, including from pathfinder authorities that tested the reforms. We are also supporting the voluntary sector to develop practice and support.
	I hope that noble Lords will recognise that what I have set out represents a significant programme of activity. Of course, we will continue to look at what more can be done to support schools and colleges in the important role that they play as the wider transformation of mental health services continues to happen.

House adjourned at 5.46 pm.